Robin Kamal MD MBA

All Publications

• The palmar intra-articular extended window approach for distal radial fractures: a biomechanical cadaveric study. The Journal of hand surgery, European volume Bronenberg Victorica, P., Shapiro, L., De Carli, P., Castro Appiani, L. M., Chan, C., Kamal, R. N. 2025: 17531934251332565

  Abstract

  A palmar intra-articular extended window approach can be used during surgical treatment of intra-articular fractures of the distal radius. A biomechanical study was carried out on 10 fresh-frozen cadaver wrists to measure the impact of the approach on proximal carpal row stability during simulated grip loading. The null hypothesis was that this approach would not generate a displacement of more than 2 mm of the scaphoid or lunate in any direction. After incising the palmar capsule, no significant increase in ulnar translation of the lunate or scaphoid was observed. However, after additionally releasing the dorsal radiocarpal ligament, increased mobility was observed, mainly in the anteroposterior axis. This approach may be suitable for the treatment of intra-articular fractures of the distal radius without causing carpal instability. However, care should be taken when there is a suspicion of dorsal wrist ligament injury. Level of evidence: Level V.

  View details for DOI 10.1177/17531934251332565

  View details for PubMedID 40231427

• An Analysis of the Study Participants and Patient-Reported Outcome Measures Used to Inform Clinical Practice Guidelines for Hip and Knee Osteoarthritis. The Journal of arthroplasty Mai, T., Julian, K. R., Ward, D., Kamal, R. N., Shapiro, L. M. 2025

  Abstract

  Clinical practice guidelines (CPGs) are developed based on the best available evidence to guide clinical decisions. Because patient language, race, and ethnicity can affect the outcomes of a clinical study, the diversity of patients in studies informing CPGs is increasingly important as it shapes the conclusions that are drawn. As such, we 1) examined the linguistic, racial, and ethnic representation of patients enrolled in studies informing CPGs for hip and knee osteoarthritis (OA); and 2) evaluated the utilization of appropriately translated and culturally adapted patient-reported outcome measures (PROMs) in these studies.Studies utilized to develop the American Academy of Orthopaedic Surgeons (AAOS) CPGs for hip and/or knee OA were evaluated, including their registered clinical trials, if applicable. Variables extracted included country of study, inclusion and exclusion criteria, patient language and proficiency, patient race and ethnicity, and report of PROM translation, and/or cultural adaptation. Extracted variables were reported descriptively.In the AAOS CPGs, 65 studies were identified for hip OA, 503 for knee OA, and 16 examined OA of both joints. Among all included articles, 46 (8%) reported patient language, 76 (13%) reported race, 18 (3%) reported ethnicity, 70 (14%) reported use of translated PROMs, and 21 (4%) reported use of culturally adapted PROMs. Among 30 multinational studies that utilized PROMs, two (7%) reported the use of translated or culturally adapted PROMs. Individual analysis of registered clinical trial databases revealed similar reporting rates of these variables.Patient language, race, and ethnicity are infrequently reported among studies used to inform CPGs for hip and knee OA. Moreover, linguistic and cultural adaptations of PROMs are often not reported or utilized. Orthopaedic studies, especially those informing CPGs, should report patient demographic data to promote inclusivity, enhance validity, and ensure results are generalizable to diverse patient populations.

  View details for DOI 10.1016/j.arth.2025.04.003

  View details for PubMedID 40216274

• Establishing Clinically Operational Domains of Multidimensional Frailty: A Consensus Approach to Improve Multidimensional Frailty Diagnosis at Point of Care. The Gerontologist Shapiro, L. M., Arya, S., Adeli, E., Fredericson, M., Kaplan, R. M., Eppler, S. L., Lorenz, K., Lorig, K., Marwell, J., Schmiesing, C., Schroeder, R., Schulman, K., Trivedi, R., Kamal, R. 2025

  Abstract

  Frailty is common amongst older patients, however, there is a lack of agreement on methods to diagnose and monitor frailty at point of care. The purpose of this study was to establish consensus on important, feasible, and usable domains for point of care frailty assessment within all conceptual models of frailty.We reviewed instruments that assess frailty and extracted the domains measured by each tool. We developed 3 use cases for frailty assessment which provided context for voters: (1) longitudinal tracking of frailty in the aging patient (>50 years), (2) preoperative evaluation of frailty before surgery in adults (>50 years), and (3) discharge disposition after hospital admission in adults (>50 years). We conducted a modified RAND/UCLA Delphi with a panel of 11 experts. Panelists rated each domain for each use case on a scale from 1 to 9, where 1 is definitely not important/feasible/usable and 9 is definitely important/feasible/usable.Panelists achieved agreement on the following domains for the respective clinical use cases: Physical Strength 1, 2, and 3; Balance 1 and 3; Cognition 1, 2, and 3; Nutrition 1; Physical Activity 1, 2, and 3; Depression 1; Disease 1, 2, and 3; and Social Environment 1 and 3. The remaining items were indeterminate.We established consensus on eight domains of frailty across three use cases. These results can inform the measurement of domains to diagnose, monitor, and inform the management of frailty within the defined use cases.

  View details for DOI 10.1093/geront/gnae183

  View details for PubMedID 40119454

• Development of International Quality Measures Targeting Low-Value Care in Hand Surgery. The Journal of hand surgery Schultz, E. A., Kamal, R. N., Shapiro, L. M. 2025

  Abstract

  Low-value care, defined as care in which there is no evidence of benefit, increases the risk of harm, or adds unnecessary costs, persists in hand and upper extremity care globally. To date, there are no quality measures to measure low-value care for a global setting. We aimed to develop international quality measures that are important, feasible, usable, and scientifically acceptable for reducing low-value care in hand surgery.We performed a literature review to identify areas of potential low-value care for hand surgery. A consortium of 11 United States-based surgeons with experience in hand and upper-extremity surgery and/or quality measure development completed a modified Research and Development (RAND)/ University of California, Los Angeles (UCLA) Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of 10 candidate quality measures to reduce low-value hand surgical care. A modified RAND/UCLA Delphi Appropriateness process was subsequently conducted that included a panel of 20 international hand surgeons who voted on the same 10 measures using the same voting criteria. Panelist agreement or disagreement was assessed using predetermined criteria.United States and international panelists achieved agreement on the four criteria for five of the 10 measures; thus, these five measures were deemed valid. These measures include minimizing the unnecessary use of immobilization for fifth metacarpal neck fractures, postinjury imaging of distal radius fractures, perioperative antibiotics for soft tissue hand surgery, pre-operative testing, and opioid use after hand surgery. Two measures were deemed valid by the US panelists only, and two measures were deemed valid by the international panel only.United States- and international-based hand and upper-extremity surgeons achieved consensus on an international quality measure portfolio to reduce low-value care in hand surgery, which may vary in practices settings globally.These quality measures may be used to reduce low-value care in many types of health systems globally.

  View details for DOI 10.1016/j.jhsa.2024.12.010

  View details for PubMedID 39891621

• Improved Risk Adjustment for Comorbid Diagnoses in Administrative Claims Analyses of Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Koltsov, J. C., Zhuang, T., Hu, S. S., Kamal, R. N. 2025

  Abstract

  The accurate inclusion of patient comorbidities ensures appropriate risk adjustment in clinical or health services research and payment models. Orthopaedic studies often use only the comorbidities included at the index inpatient admission when quantifying patient risk. The goal of this study was to assess improvements in capture rates and in model fit and discriminatory power when using additional data and best practices for comorbidity capture.Hip fracture care was used as an exemplary case of an inpatient condition in a population typically having multiple comorbidities. Cohorts were built from 3 administrative resources: (1) Medicare, (2) all-payer, and (3) private-payer. Elixhauser comorbidities were calculated first using only the index admission and subsequently by adding inpatient and outpatient data from the previous year. Comorbidities identified on outpatient records required 2 instances occurring ≥30 days apart. Model fit and discriminatory power for in-hospital metrics (death, length of stay, and costs or charges) and post-discharge metrics (90-day readmission and surgical site infection, and 90-day and 1-year death) were compared among capture strategies.The index admission missed 9.3% to 65.6% of individual Elixhauser comorbidities for the Medicare cohort, 2.9% to 39.0% for the all-payer cohort, and 14.1% to 57.9% for the private-payer cohort compared with data from the index admission plus the previous year. Using prior inpatient and outpatient data provided substantial improvements in model fit and explanatory power for post-discharge outcomes, whereas information from the index admission was sufficient for in-hospital death and length of stay. The utility of outpatient data was greatest when complete outpatient claims were captured compared with only ambulatory surgery claims.The comorbidity capture strategies demonstrated in this study, namely including all available data for post-discharge outcomes, using a 1-year lookback period, and requiring outpatient codes to appear on 2 claims ≥30 days apart, are relevant for improved risk adjustment in orthopaedic clinical or health services research and quality improvement and payment models.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.23.01451

  View details for PubMedID 39879281

• Is Area-Level Social Vulnerability Index Associated With Patient-Level Health-Related Social Needs in Hand Surgery? The Journal of the American Academy of Orthopaedic Surgeons Schultz, E. A., Zhuang, T., Shapiro, L. M., Kamal, R. N. 2025

  Abstract

  Social drivers of health (SDOH) are area-level, nonmedical factors that affect health outcomes. By contrast, health-related social needs (HRSNs) are individual patient reported and are being deployed in some payment models. SDOH are often used to broadly represent health disparities of communities through metrics, such as the Social Vulnerability Index (SVI); however, the association of area-level SVI to individual HRSNs has not been well studied in hand surgery, which has implications for addressing social risks to improve health and in quality measurement.We conducted a prospective cohort study of new patients presenting to an outpatient hand surgery clinic. Patients completed a questionnaire that included demographic information, zip code, the Accountable Health Communities HRSNs Screening Tool, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). Following completion of the survey, zip code was used to calculate SVI. Cohen kappa coefficients (k) were calculated to measure interrater agreement between SVI and HRSNs, SVI and QuickDASH, and HRSNs and QuickDASH.We included 80 patients in the study. The most commonly reported HRSNs were safety (33, 41.25%) followed by housing (14, 17.5%) and food (11, 13.75%). Seven SVIs were represented across the cohort. No notable agreement was observed between SVI and HRSNs. In addition, no notable agreement was observed between SVI or HRSNs and QuickDASH score.Although the importance of identifying SDOH is growing, the ability of these area-level measures to accurately reflect individual HRSNs is not well understood. HRSNs may represent an opportunity for patient-centered assessments of needs and to guide resource deployment to improve outcomes for hand surgery patients.Level II prognostic study.

  View details for DOI 10.5435/JAAOS-D-24-00989

  View details for PubMedID 39841961

• Time-dependent, patient-centered perceptions of quality measures for total joint arthroplasty: a cross-sectional, choice modeling study. BMC musculoskeletal disorders Lemos, J. L., Welch, J. M., Amanatullah, D. F., Shapiro, L. M., Harris, A. H., Kamal, R. N. 2025; 26 (1): 41

  Abstract

  BACKGROUND: As value-based care arrangements continue to assess quality of care and costs, comprehensive and patient-centered definitions of quality of care are required. While patient-reported outcome measures are increasingly integrated into quality assessments following total joint arthroplasty (TJA), patient perceptions of quality paired with the phase of surgical care has not been described. The purpose of this study was to assess how TJA patients perceive measures of quality of care and assess if these perceptions change based on the phase of care.METHODS: Patients who had undergone a TJA within the past two years or had a scheduled TJA within the next 6 months completed a questionnaire designed using best-worst scaling, a method used to measure individuals' priorities by asking participants to make repeated selections of the best and worst items in a series of subsets of items. Subanalyses were calculated to compare each phase of care (preoperative, short term postoperative, and long term postoperative).RESULTS: A total of 153 patients completed the questionnaire; 36 were preoperative, 55 were short term postoperative, and 62 were long term postoperative. Patients placed the highest value on improving activities of daily living (beta=1.03, CI=0.90-1.16), decreasing pain (beta=0.65, CI=0.53-0.76), and avoiding re-intervention (beta=0.64, CI=0.52-0.76). Decreasing pain ranked as a higher priority preoperatively compared to short term postoperatively, and subsequently increased in priority again after 6 months. Avoiding reintervention was less important to patients preoperatively compared to postoperatively. Avoiding complications was more important to patients preoperatively compared to postoperatively.CONCLUSIONS: Matching outcome assessments with how patients assess their quality of care throughout the TJA recovery process can inform phase-specific quality improvement initiatives and value definitions. Activities of daily living should be measured across phases of care and into long-term recovery. TJA value dashboards should align with these patient-driven perceptions of quality.LEVEL OF EVIDENCE: Level III, cohort study.

  View details for DOI 10.1186/s12891-025-08284-w

  View details for PubMedID 39806343

• American Academy of Orthopaedic Surgeons/ASSH Clinical Practice Guideline Summary Management of Carpal Tunnel Syndrome. The Journal of the American Academy of Orthopaedic Surgeons Shapiro, L. M., Kamal, R. N., Management of Carpal Tunnel Syndrome Work Group, American Academy of Orthopaedic Surgeons 2024

  Abstract

  Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies with regard to the diagnosis and treatment of carpal tunnel syndrome in adult patients (≥18 years of age). The scope of this guideline addresses the diagnosis and treatment of carpal tunnel syndrome and contains nine recommendations to assist orthopaedic surgeons and all qualified clinicians managing patients presenting with signs and symptoms which may be attributable to carpal tunnel syndrome based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners, health services researchers, and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

  View details for DOI 10.5435/JAAOS-D-24-01179

  View details for PubMedID 39637428

• MRI for Scaphoid Nonunion: Utilization Rates, Factors Associated with Utilization, and Subsequent Vascularized Bone Graft Use. The Journal of hand surgery Shapiro, L. M., Schultz, E. A., Welch, J., Zhuang, T., Kamal, R. N. 2024

  Abstract

  The use of magnetic resonance imaging (MRI) for evaluation of scaphoid nonunion may be an example of low-value imaging for the treatment of scaphoid nonunion. The purpose of this study was to investigate variation in MRI use for scaphoid nonunion, the association of MRI with a vascularized bone graft (VBG) and to develop consensus on MRI use for scaphoid nonunion.We identified patients >18 years of age who underwent scaphoid nonunion surgery between 2010 and 2019 using a claims database. Patients who had, and did not have, an MRI within 90 days prior to their diagnosis of scaphoid nonunion were included and a multivariable analysis was performed to evaluate variation in MRI and VBG use. Subsequently, a literature review was performed, and a preliminary consensus statement was developed pertaining to the routine use of MRI for scaphoid nonunion. A consortium of nine hand surgeons evaluated the importance, feasibility, usability, and scientific acceptability of the statement through a modified RAND Coroporation/University of California, Los Angeles Delphi. Panelists evaluated the statement in two voting rounds with an intervening face-to-face discussion.We identified 1,324 eligible patients with surgical repair of a scaphoid nonunion. Two hundred and sixty-three (19.9%) underwent an MRI within 90 days prior to surgery. Differences in age, insurance type, and comorbidity burden existed between patients who received MRI and those who did not. The MRI cohort was more likely to receive VBG (10.6%) compared to those without an MRI (4.7%). Panelists agreed on the voting domains of the consensus statement and therefore the statement, "There is no benefit of routine MRI/MRA in the treatment of scaphoid nonunion with or without presumed avascular necrosis," was considered valid.MRI use within 90 days of surgical repair of scaphoid nonunion varies, is associated with greater rates of VBG use, and may represent low-value imaging given the lack of sufficient evidence on this topic.As MRI use for scaphoid nonunion varies and may represent low-value imaging, a validated consensus statement may help guide the evaluation of patients with scaphoid nonunion.

  View details for DOI 10.1016/j.jhsa.2024.10.008

  View details for PubMedID 39614839

• Integrated Compression Screw Versus Unicortical Locking Screw for Fixing the Dorsal Critical Corner in Distal Radius Fractures: A Biomechanical Study. The Journal of hand surgery Bronenberg Victorica, P., Shapiro, L. M., Chan, C., De Carli, P., Castro Appiani, L. M., Kamal, R. N. 2024

  Abstract

  Although studies have demonstrated that locked screws with a length of 75% of the radius width are sufficient for the treatment of extra-articular fractures of the distal radius, the application of this principle to intra-articular fractures is less well-understood. This study aimed to evaluate the biomechanical properties of different types of volar plate fixation constructs for the treatment of distal radius fractures in the presence of a dorsal critical corner fragment.A dorsal critical corner fracture was created in 18 synthetic distal radius models. The fragment was stabilized with one of three constructs: a posteroanterior integrated compression screw (group 1) or volar locking screws with a length of 90% or 75% of the volar/dorsal width of the radius (groups 2 and 3, respectively). For the biomechanical evaluation, a load was applied to the lunate facet. Fixation stiffness and loads to produce clinical and catastrophic failures were compared among the groups.The stiffness (N/mm) was 67.8 (SD, 14.7), 64.9 (SD, 8.63), and 65.8 (SD, 36.02) for groups 1, 2, and 3, respectively. The load required to generate a catastrophic displacement was 532.9 (SD, 142.32), 307.4 (SD, 101.51), and 230.8 N (SD, 77.68) for groups 1, 2, and 3, respectively. The load required to produce a 2-mm translation of the fixed fragment was 127.9 N (SD, 28.8) for group 1, 119.7 (SD, 11.78) for group 2, and 127.6 N (SD, 46.2) for group 3.Significantly greater load is required for catastrophic failure after fixation of a dorsal critical corner fracture with an integrated compression screw; however, it provides similar stiffness and load to failure for 2 mm of translation.For the treatment of intra-articular distal radius fractures with dorsal critical corner fragments, an integrated compression screw may be considered for rigid fixation of the fragment to support early return to daily activities.

  View details for DOI 10.1016/j.jhsa.2024.10.014

  View details for PubMedID 39601736

• Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series. Clinical orthopaedics and related research Schultz, E. A., Gomez, G. I., Gardner, M. J., Hu, S. S., Safran, M., Amanatullah, D. F., Shapiro, L. M., Kamal, R. N. 2024

  Abstract

  Pain self-efficacy, or the ability to carry out desired activities in the presence of pain, can affect a patient's ability to function before and after orthopaedic surgery. Previous studies suggest that shared decision-making practices such as discussing patient-reported outcome measures (PROMs) can activate patients and improve their pain self-efficacy. However, the ability of PROMs to influence pain self-efficacy in patients who have undergone orthopaedic surgery has yet to be investigated.(1) Is immediately discussing the results of a PROM associated with an increase pain self-efficacy in new patients presenting to the orthopaedic surgery clinic? (2) Is there a correlation between patient resilience or patient involvement in decision-making in changes in pain self-efficacy?This was a prospective, sequential, comparative series completed between February to October 2023 at a single large tertiary referral center at a multispecialty orthopaedic clinic. Orthopaedic subspecialties included total joint arthroplasty, spine, hand, sports, and trauma. The first 64 patients underwent standard care, and the following 64 had a conversation with their orthopaedic surgeon about their PROMs during the initial intake visit. We collected scores from the Pain Self-Efficacy Questionnaire (PSEQ), Brief Resilience Scale (BRS), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function form (PF-SF10a) and data on demographic characteristics before the visit. The PSEQ is a validated PROM used to measure pain self-efficacy, while the BRS measures the ability of patients to recover from stress, and the PROMIS PF-SF10a is used to assess overall physical function. PROMs have been utilized frequently for their ability to report the real-time physical and psychological well-being of patients. In the standard care group, the PROMIS PF-SF10a score was not discussed with the patient. In the PROMs group, the physician discussed the PROMIS PF-SF10a score using a script that gave context to the patient's score. Additional conversation about the patient's score was permitted but not required for all patients. Scores from the Observing Patient Involvement in Decision Making (OPTION-5) instrument were recorded during the visit as a measure of patient involvement in clinical decision-making. After the visit, both groups completed the PSEQ. The primary outcome was change in the PSEQ. Change in pain self-efficacy was recorded as greater or less than the minimum clinically important difference, previously defined at 8.5 points for the PSEQ [10]. The secondary outcomes were correlation between PSEQ change and the BRS or OPTION-5.Between the PROMs and standard care groups, there was no difference in the change in PSEQ scores from before the visit to after (mean ± SD change in control 4 ± 10 versus change in PROMs group 3 ± 7, mean difference 1 [95% confidence interval (CI) -2.0 to 4.0]; p = 0.29). Fifty-six percent (36 of 64) of patients in the standard care group demonstrated an increase in pain self-efficacy (of whom 22% [14 of 64] had clinically important improvements), and 59% (38 of 64) of patients in the PROMs group demonstrated an increase in pain self-efficacy (of whom 19% [12 of 64] had clinically important improvements). In the control group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.13 [95% CI -0.36 to 0.12]; p = 0.30) or patient involvement in decision-making (OPTION-5 r = 0.003 [95% CI -0.24 to 0.25]; p = 0.98). Similarly, in the PROMs group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.10 [95% CI -0.33 to 0.16]; p = 0.45) or patient involvement in decision-making (OPTION-5 r = -0.02 [95% CI -0.26 to 0.23]; p = 0.88).Discussing PROMs results (PROMIS PF-SF10a) at the point of care did not increase pain self-efficacy during one visit. Therefore, surgeons do not need to discuss pain self-efficacy PROM scores in order to influence patient pain self-efficacy. While PROMs remain valuable tools for assessing patient outcomes, further work may assess whether the collection of PROMs itself may increase pain self-efficacy or whether longitudinal discussion of PROMs with patients changes pain self-efficacy.Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000003325

  View details for PubMedID 39589313

• Claims Database Research in Hand Surgery: From Data to Bedside. The Journal of hand surgery Zhuang, T., Shapiro, L. M., Kamal, R. N. 2024

  Abstract

  The widespread availability of administrative claims data has unlocked opportunities to answer challenging clinical questions in hand surgery, overcoming the limitations of traditional data sets. Researchers are taking advantage of claims data sets to obtain samples from broader segments of the population and achieve statistical power that was previously unattainable. Therefore, a basic understanding of claims database research is quickly becoming an invaluable tool in the surgeon's toolkit, enabling the performance of ground-breaking research and the critical evaluation of data-driven results to inform clinical practice. We provide an overview of methodological approaches to claims data analysis for hand surgery and a roadmap for analyzing and interpreting these studies in clinical practice.

  View details for DOI 10.1016/j.jhsa.2024.10.004

  View details for PubMedID 39580752

• A 3-Dimensional Printed Dynamic External Fixator for the Treatment of Proximal Interphalangeal Fracture-Dislocations: A Biomechanical Study. The Journal of hand surgery Bronenberg Victorica, P., Albani-Forneris, A., Holc, F., Shapiro, L. M., Kamal, R. N., Boretto, J. G. 2024

  Abstract

  PURPOSE: This study evaluated the efficacy of a 3-dimensional printed dynamic external fixator for treating proximal interphalangeal (PIP) fracture-dislocations. The null hypothesis was that there would be no difference in maintaining PIP joint reduction between a 3-dimensional printed dynamic external fixator (3DPDEF) and the pins and rubbers traction system (PRTS).METHODS: Ten cadaveric fingers underwent an oblique osteotomy at the base of the middle phalanx, recreating an unstable dorsal PIP fracture-dislocation. The percentages of compromised articular surface and middle phalanx dorsal displacement were measured. Both fixators were randomly placed on each digit and underwent 1,400 flexion-extension cycles. Efficacy, determined by joint reduction and maintenance of dorsal translation correction, was assessed using fluoroscopy before and after the cycles.RESULTS: The mean compromised articular surface was 50.8%. After osteotomy, PIP joint subluxation occurred at 37.8° flexion. Dorsal translation after osteotomies was 2.8 mm. After applying the 3DPDEF and the PRTS, it was 0 mm and 0.1 mm, respectively. During the cycles, all the joints remained stable and reduced. Dorsal displacement after cycles was-0.1 mm for the 3DPDEF and 0 mm for the PRTS. The mean translation difference between both fixators was 0.1 and 0 mm before and after the cycles. The translation differences before and after the cycles were 0.1 mm for both dynamic fixators.CONCLUSIONS: The 3DPDEF is a suitable option for PIP fracture-dislocations, providing stability comparable to that of the PRTS while offering benefits, such as easy placement, controlled distraction, and clear visualization of the articular surface.CLINICAL RELEVANCE: This external fixator, characterized by its efficacy, low cost, and simplicity of application, broadens the options available to address PIP fracture-dislocations.

  View details for DOI 10.1016/j.jhsa.2024.09.019

  View details for PubMedID 39503633

• Utilization of Surgical Fixation for Distal Radius Fractures in the United States: A Population-Based Cohort Study. The Journal of hand surgery Zhuang, T., Young, B., Shapiro, L. M., Kamal, R. N. 2024

  Abstract

  In contrast to younger adult populations, clinical practice guidelines state that there is no difference in long-term functional outcomes in surgically versus nonoperatively treated distal radius fractures in patients ≥65 years old. In this study, we asked the following questions: (1) has treatment for distal radius fractures in younger and older adult populations changed over time? (2) What patient and surgeon factors are associated with treatment trends?Using a national administrative claims database, we identified patients aged ≥18 years with isolated, closed distal radius fractures, subdivided by age (18-64 years, ≥65 years old). We characterized the proportion of patients who underwent open reduction and internal fixation (ORIF) over time. We stratified our analysis by surgeon subspecialty, region, and mean area income. Changes in ORIF utilization over time were evaluated using linear regression models.The proportion of distal radius ORIF, including in patients aged ≥65 years, increased from 10.4% in 2012 to 15.1% in 2020. Of the ORIF procedures performed, hand surgeons accounted for an increasing proportion over time, with a corresponding decrease in those performed by general orthopedic surgeons. The proportion of ORIF increased over time in all US regions, with the largest rate of increase in the Midwest for patients aged ≥65 years and Northeast for patients aged 18-64 years. Patients living in areas with mean family income ≥$65,000 were more likely to undergo ORIF.The proportion of distal radius ORIF including in older adult populations is increasing in all US regions, and an increasing proportion is performed by hand surgeons.Further analysis of the drivers of these trends is warranted, given the rising incidence of surgical treatment in older patients, which could reflect evolving patient activity demands and suggest a need to further evaluate conventional treatment algorithms based on age.

  View details for DOI 10.1016/j.jhsa.2024.09.014

  View details for PubMedID 39488766

• Quality Measures Addressing Orthopaedic Surgery in Ambulatory Surgery Centers: A Systematic Review Snyder, E., Schultz, E. A., Shapiro, L. M., Kamal, R. N. LIPPINCOTT WILLIAMS & WILKINS. 2024: S333-S334

  View details for Web of Science ID 001348680702141

• A Quantitative Assessment to Support Orthopaedic Surgery Capacity-Building in Palau Snyder, E., Dever, G. J., Kamal, R. N., Shapiro, L. M. LIPPINCOTT WILLIAMS & WILKINS. 2024: S223

  View details for Web of Science ID 001348680701183

• Surgeon Alignment With Clinical Practice Guidelines: A Qualitative Analysis of Treatment of Distal Radius Fractures. Hand (New York, N.Y.) Schultz, E. A., Eppler, S. L., Shapiro, L. M., Kamal, R. N. 2024: 15589447241277843

  Abstract

  Clinical practice guidelines (CPGs) are developed to guide physicians in providing consistent high-quality care. Despite availability of evidence-based guidelines for the treatment of distal radius fractures, prior work suggests many patients receive treatment that is misaligned with the CPG. We sought to explore barriers and facilitators of guideline-aligned care for distal radius fractures.We conducted semistructured interviews of a purposive sample of surgeons who treat distal radius fractures. Our interview guide was based on the Theoretical Domains Framework (TDF). Interviews were transcribed and coded using a deductive analytical approach within the 14 TDF domains. Belief statements underlying similar codes were developed to describe barriers and facilitators of guideline-aligned care. A content analysis was performed to count the frequency of each TDF domain.We interviewed 14 surgeons. The most common TDF domains were beliefs about consequences (110), knowledge (49), and social influences (29). Belief statements representative of barriers of concordance to the CPGs included, "I am more likely to deviate from the CPGs when the CPGs differ from my professional opinion," which was coded under beliefs about consequences. Similar belief statements were created for each theme within TDF domains.Decision-making for patients with distal radius fractures is driven by beliefs about consequences, knowledge, and social influences. Strategies to address these beliefs in other fields such as including patient factors in a further structured shared decision-making process, developing implementation toolkits as part of the CPG development process, and implementing payment programs may improve CPG alignment.

  View details for DOI 10.1177/15589447241277843

  View details for PubMedID 39370690

• A Biomechanical Analysis of Oblique Metacarpal Metadiaphyseal Fracture Fixation in a Cadaver Model. The Journal of hand surgery Garcia-Lopez, E., Siu, J. W., Kwong, J. W., Kamal, R. N., Schroeder, N., Shapiro, L. M. 2024

  Abstract

  Although metacarpal fractures are typically managed nonoperatively, when surgical management is indicated, metacarpal fractures are commonly treated with crossed Kirschner wires (K-wires), which may limit early range of motion. Intramedullary implants are increasing in use with the potential advantage of early range of motion; however, stability in oblique metacarpal neck fractures remains a theoretical concern. The purpose of this study was to determine the biomechanical stability of noncompressive intramedullary fixation for oblique metacarpal neck fractures compared with crossed K-wire fixation.The index, long, and small metacarpals were harvested from three matched pairs of fresh-frozen cadavers. Oblique fractures at the metadiaphyseal region were created in each metacarpal. Each metacarpal was randomized to noncompressive, threaded intramedullary nail fixation or fixation with two crossed K-wires. Specimens were mounted in a Materials Testing System load frame and axially loaded until failure. Load to failure (LTF), stiffness, and load to 2 mm displacement were calculated from load-displacement curves. Differences in peak LTF, stiffness, and load to 2 mm displacement between noncompressive intramedullary fixation and crossed K-wire fixation were evaluated.The noncompressive intramedullary fixation cohort had a significantly higher LTF (1,190.9 ± 534.7 N vs 297.0 ± 156.0 N) and stiffness (551.3 ± 164.6 N/mm vs 283.0 ± 194.5 N/mm) when compared with the crossed K-wire fixation cohort. Load at 2 mm displacement was greater in the noncompressive intramedullary fixation cohort compared with crossed K-wire fixation (820.5 ± 203.9 vs 514.1 ± 259.6).For oblique metadiaphyseal metacarpal fractures, noncompressive intramedullary fixation provides a biomechanically superior construct under axial loading in terms of LTF, stiffness, and load to 2 mm of displacement compared with crossed K-wire fixation.Noncompressive intramedullary nails may be an alternative to K-wire fixation for the treatment of oblique metadiaphyseal metacarpal fractures.

  View details for DOI 10.1016/j.jhsa.2024.08.009

  View details for PubMedID 39352346

• Goal Concordant Care: A Cross-Sectional Study Evaluating Correlates of Concordant Care and Association With Satisfaction and Outcomes. Hand (New York, N.Y.) Julian, K. R., Kwong, J. W., Leversedge, C., Zhuang, T., Schroeder, N., Kamal, R. N., Shapiro, L. M. 2024: 15589447241279458

  Abstract

  BACKGROUND: The concordance between patient and physician goals has been associated with improved outcomes in many chronic diseases. The purpose of this study was to evaluate the association between goal concordant care, patient satisfaction, and patient experience and to analyze factors associated with goal concordant care in hand and upper extremity surgery.METHODS: New patients who were 18 years or older were invited to participate. Goal concordant care was defined as the patient's previsit treatment goal matching the primary treatment received. The chi2 tests were used to evaluate the association between goal concordant care and patient satisfaction and patient experience. We conducted univariable logistic regression to evaluate variables for their association with concordance and multivariable logistic regression for variables that were significantly associated in the initial analyses to evaluate their aggregate influence on concordance.RESULTS: In total, 169 patients enrolled. The rate of goal concordant care was 62%; concordance was not associated with patient satisfaction or experience. Age, sex, English proficiency, health literacy, education level, employment and relationship status, pain self-efficacy, symptom duration, functional disability, and patient-centered decision-making were not associated with concordant care. Patients with annual income less than $50,000 had significantly higher odds of goal discordant care.CONCLUSION: Patients with lower income had more than 3 times the odds of receiving discordant care. However, discordant care was not associated with patient satisfaction or experience. Further studies on other pertinent outcomes are needed in orthopedic surgery (eg, treatment adherence). Known care disparities based on socioeconomic status may be mediated through care discordance and should be investigated.

  View details for DOI 10.1177/15589447241279458

  View details for PubMedID 39324747

• Disparities Exist in Knowledge of Hip Fracture Compared With Stroke and Myocardial Infarction ORTHOPEDICS Choy, S., Zhuang, T., Shapiro, L., Kamal, R. 2024: 1-7

  Abstract

  This study sought to answer the following questions: (1) Are there differences in knowledge on time to treatment (TTT) between stroke, myocardial infarction (MI), and hip fractures in the general population? (2) Are there differences in condition-specific knowledge across these conditions? (3) Are there underlying demographic factors that may contribute to differences in hip fracture-specific knowledge?This was a cross-sectional cohort analysis. Participants were acquired using an online survey distribution platform, Amazon Mechanical Turk (MTurk). Individuals older than 18 years with English fluency and literacy were included. A total of 913 participants who completed a survey with questions on TTT knowledge, condition-specific knowledge, history of hip fracture, and demographics were recruited.On comparing TTT knowledge, the MI mean score was 36.92% higher than that of hip fractures (P<.0001). On comparing condition-specific knowledge, the MI-specific mean score was 8.24% higher than that of hip fractures (P<.0001). Hip fracture knowledge was associated with demographic factors. Asian and Black participants and participants with Medicaid or Medicare as their primary insurance type were associated with significantly lower hip fracture knowledge.Hip fracture knowledge was significantly lower than MI knowledge in the study population. Just as professional societies have invested resources in public education campaigns on the importance of TTT for stroke and MI, public education campaigns on the importance of TTT for hip fractures may support earlier TTT for populations vulnerable to delays (Asian and Black). [Orthopedics. 20XX;4X(X):XXX-XXX.].

  View details for DOI 10.3928/01477447-20240826-05

  View details for Web of Science ID 001322776700001

  View details for PubMedID 39208399

• Opioid Use After Robotic-Assisted Versus Conventional Total Hip Arthroplasty: A National Database Analysis ORTHOPEDICS Zhuang, T., Young, B., Hooper, J., Amanatullah, D. F., Shapiro, L., Kamal, R. N. 2024; 47 (5): 289-+

  Abstract

  In this study, we tested the null hypothesis that robotic-assisted total hip arthroplasty (THA) vs conventional THA was not associated with (1) the amount of postoperative opioid use and (2) the incidence of new, persistent opioid use.We used a large, national administrative database to identify patients 50 years and older undergoing primary robotic or conventional THA. Patients with hip fractures or a history of malignancy, hip infection, or opioid use disorder were excluded. Patients who filled an opioid prescription within 1 year to 30 days preoperatively or who underwent a subsequent procedure within 1 year after THA were excluded. Outcomes included the morphine milligram equivalents (MMEs) filled within the THA perioperative period and the incidence of new, persistent opioid use. Multivariable logistic regression models were used to evaluate associations between robotic-assisted THA and new, persistent opioid use, adjusting for age, sex, insurance plan, region, location of surgery, and comorbidities.In the postoperative period, robotic-assisted THA, compared with conventional THA, was associated with a lower mean total MMEs filled per patient (452.2 vs 517.1; P<.001) and a lower mean MMEs per patient per day (71.53 vs 74.64; P<.001). Patients undergoing robotic-assisted THA had decreased odds of developing new, persistent opioid use compared with patients undergoing conventional THA (adjusted odds ratio, 0.82 [95% CI, 0.74-0.90]).Robotic-assisted THA is associated with lower postoperative opioid use and a decreased odds of developing new, persistent opioid use compared with conventional THA. For the purposes of reducing opioid use, our results support the adoption of robotic-assisted THA. [Orthopedics. 2024;47(5):289-294.].

  View details for DOI 10.3928/01477447-20240702-03

  View details for Web of Science ID 001348283400017

  View details for PubMedID 38976847

• Current Use of Patient-Reported Outcome Measures Ignores Functional Demand. The Journal of the American Academy of Orthopaedic Surgeons Kamal, R. N., Gomez, G., Chakraborty, A., Leversedge, C., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S. S., Safran, M., Zhuang, T., Shapiro, L. M. 2024

  Abstract

  Patient-reported outcome measures (PROMs) are used in orthopaedic surgery to measure aspects of musculoskeletal function that are important to patients, such as disability and pain. However, current assessments of function using PROMs do not necessarily consider a patient's functional demands in detail. A patient's functional demands could serve as a confounder to their perception of their functional ability. Hence, functional demands may need to be adjusted for when PROMs are used to measure musculoskeletal function.We conducted a cross-sectional study in which new orthopaedic patients completed a questionnaire regarding demographics, function [Patient-Reported Outcomes Measurement Information System], functional demand (Tegner Activity Level Scale), pain self-efficacy, and symptoms of depression. 169 eligible patients with diverse orthopaedic conditions were enrolled in the study from an orthopaedic clinic, and 19 were excluded for incomplete questionnaires.The mean Patient-Reported Outcomes Measurement Information System score was 36.5 ± 9.1, and the mean Tegner score was 2.6 ± 2.0. In the multivariable regression model, patient-reported function was significantly associated with functional demand (β = 0.17, P < 0.001). Significant associations were observed for pain self-efficacy (β = 0.15, P < 0.001), acuity (β = -0.10, P = 0.004), and age 80 years or older (β = -0.16, P = 0.004). No notable association was observed with depression or age 65 to 79 years.Higher patient-reported physical function is associated with higher levels of functional demand when controlling for psychosocial factors, acuity, and age. Because of its confounding effect on measuring physical function, functional demand should be assessed and included in models using PROMs before and after surgery. For example, payment models using improvements in PROMs, such as the short form of the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score after joint arthroplasty, should include functional demand in the model when assessing quality of care.Level II.

  View details for DOI 10.5435/JAAOS-D-24-00069

  View details for PubMedID 39186610

• Health Numeracy Is Associated With a Patient's Ability to Interpret Patient-Reported Outcome Measures Data. Orthopedics Schultz, E. A., Eppler, S. L., Gardner, M., Hu, S. S., Chou, L., Safran, M., Amanatullah, D. F., Abrams, G. D., Shapiro, L. M., Kamal, R. N. 2024: 1-6

  Abstract

  Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results.We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results.Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions.Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 202x;4x(x):xx-xx.].

  View details for DOI 10.3928/01477447-20240718-04

  View details for PubMedID 39073043

• Performing region-specific tasks does not improve lower extremity patient-reported outcome scores. Arthroplasty (London, England) Korth, M. J., Banta, W. A., Arora, P., Kamal, R. N., Amanatullah, D. F. 2024; 6 (1): 42

  Abstract

  BACKGROUND: Patient-reported outcome measures quantify outcomes from patients' perspective with validated instruments. QuickDASH (Quick Disability of Arm, Shoulder and Hand, an upper extremity PROM) scores improve after completing instrument tasks, suggesting patient-reported outcome results can be modified. We hypothesized that performing lower extremity tasks on the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS-JR) and hip disability and osteoarthritis outcome score for joint reconstruction (HOOS-JR) instruments would similarly improve the scores.METHODS: Forty seven hip and 62 knee osteoarthritis patients presenting to a suburban academic center outpatient osteoarthritis and joint replacement clinic were enrolled and randomized to an intervention or a control group. Inclusion criteria were age over 18years and English competency. Patients completed a HOOS-JR or KOOS-JR instrument, completed tasks similar to those of the instrument (intervention) or the QuickDASH (control), and then repeated instruments again. Paired and unpaired t-tests were used to compare the intervention and control group scores before and after tasks.RESULTS: There was no significant difference in total or individual scores after task completion compared to baseline in either the HOOS-JR or the KOOS-JR groups. There was no significant difference in the scores between the intervention or control groups.CONCLUSIONS: Disability may be less modifiable in the lower extremity than in the upper extremity, perhaps because upper extremity activities are more easily compensated by the contralateral limb, or because lower extremity activities are more frequent. Thorough evaluation of factors influencing patient-reported outcome measures is necessary before their extensive application to quality control and reimbursement models.

  View details for DOI 10.1186/s42836-024-00261-3

  View details for PubMedID 38971795

• Pain Self-Efficacy Can Improve During a Visit With an Orthopedic Surgeon ORTHOPEDICS Lemos, J. L., Gomez, G. I., Tewari, P., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S., Safran, M., Kamal, R. N. 2024; 47 (4): e197-e203

  Abstract

  Greater pain self-efficacy (PSE) is associated with reduced pain, fewer limitations, and increased quality of life after treatment for orthopedic conditions. The aims of this study were to (1) assess if PSE improves during a visit with an orthopedic surgeon and (2) identify modifiable visit factors that are associated with an increase in PSE.We performed a prospective observational study of orthopedic clinic visits at a multispecialty clinic from February to May 2022. New patients who presented to one of six orthopedic surgeons were approached for the study. Patients who provided consent completed a pre-visit questionnaire including the Pain Self-Efficacy Questionnaire (PSEQ) and demographic questions. A trained research member recorded the five-item Observing Patient Involvement in Decision Making Instrument (OPTION-5) score, number of questions asked, and visit duration. Immediately after the visit, patients completed a post-visit questionnaire consisting of the PSEQ and Perceived Involvement in Care Scale (PICS).Of 132 patients enrolled, 61 (46%) had improved PSE after the orthopedic visit, with 38 (29%) having improvement above a clinically significant threshold. There were no significant differences between patients with increased PSE and those without increased PSE when comparing the PICS, OPTION-5, questions asked, or visit duration.Almost half of the patients had improvement in PSE during an orthopedic visit. The causal pathway to how to improve PSE and the durability of the improved PSE have implications in strategies to improve patient outcomes in orthopedic surgery, such as communication methods and shared decision-making. Future research can focus on studying different interventions that facilitate improving PSE. [Orthopedics. 2024;47(4):e197-e203.].

  View details for DOI 10.3928/01477447-20240605-01

  View details for Web of Science ID 001274494200007

  View details for PubMedID 38864646

• The Association Between Social Determinants of Health and Distal Radius Fracture Outcomes. The Journal of hand surgery Truong, N. M., Stroud, S. G., Zhuang, T., Fernandez, A., Kamal, R. N., Shapiro, L. M. 2024

  Abstract

  The purpose of this study was to determine if adverse social determinants of health (SDOH) are associated with differential complication rates following surgical fixation of distal radius fractures and assess which SDOH domain (economic, educational, social, health care, or environmental) is most associated with postoperative complications.Using a national administrative claims database, we conducted a retrospective cohort analysis of patients undergoing open treatment for an isolated distal radius fracture between 2010 and 2020. Patients were stratified based on the presence/absence of at least one SDOH code and propensity score matched to create two cohorts balanced by age, sex (male or female), insurance type, and comorbidities. Social determinants of health examined included economic, educational, social, health care, and environmental factors. Multivariable logistic regression analyses were performed to assess the isolated effect of SDOH on 90-day and 1-year complication rates.After propensity matching, 57,025 patients in the adverse SDOH cohort and 57,025 patients in the control cohort were included. Patients facing an adverse SDOH were significantly more likely to experience 90-day complications, including emergency department visits (Odds ratio (OR): 3.18 [95% confidence interval (CI): 3.07-3.29]), infection (OR: 2.37 [95% CI: 2.12-2.66]), wound dehiscence (OR: 2.06 [95% CI: 1.72-2.49]), and 1-year complications, including complex regional pain syndrome (OR: 1.35 [95% CI: 1.15-1.58]), malunion/nonunion (OR: 1.18 [95% CI: 1.08-1.29]), and hardware removal (OR: 1.13 [95% CI: 1.07-1.20]). Additionally, patients facing an adverse SDOH had a significantly increased risk of 90-day complications, regardless of fracture severity, and patients with economic and social challenges had the highest odds of both 90-day and 1-year postoperative complications.Social determinants of health are associated with increased complications following distal radius fracture fixation, even when controlling for demographic and clinical factors. We recommend routine screening for adverse SDOH and inclusion of SDOH data into health records to not only inform quality improvement initiatives and risk adjustment for outcome-based quality measurements but also to allow providers to begin to discuss and address such barriers during the perioperative period.Prognosis II.

  View details for DOI 10.1016/j.jhsa.2024.04.009

  View details for PubMedID 38934997

• Clinical Practice Guidelines to Support Capacity Building in Orthopaedic Surgical Outreach: An International Consensus Building Approach. The Journal of bone and joint surgery. American volume Welch, J. M., Kamal, R. N., Kozin, S. H., Dyer, G. S., Katarincic, J. A., Fox, P. M., Shapiro, L. M. 2024

  Abstract

  Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel.We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it.An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques.As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs)1,2. It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs)3. Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources4-6. In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account7,8.

  View details for DOI 10.2106/JBJS.23.01414

  View details for PubMedID 38753851

• Are Clinical Practice Guidelines Representative of Patients with Distal Radius Fractures? A Review of Patient Demographics and Patient-Reported Outcome Measures Used to Inform Guidelines. The Journal of hand surgery Mulakaluri, A., Julian, K. R., Fernandez, A., Kamal, R. N., Shapiro, L. M. 2024

  Abstract

  Clinical practice guidelines (CPGs) are recommendations developed for broad application to optimize high-quality care and decision-making. The composition of patients and outcome measures used in studies informing CPGs; however, has not been rigorously evaluated. With growing evidence that outcomes in musculoskeletal surgery vary by sociocultural factors, we aimed to: (1) review the linguistic, racial, and ethnic representation of the patients in the studies informing CPGs for distal radius fractures and (2) assess their use of linguistically and culturally adapted patient-reported outcome measures (PROMs).The American Academy of Orthopaedic Surgeons website was used to identify relevant studies. Key variables were extracted, including inclusion and exclusion criteria, language of study, patient language and proficiency, patient race and ethnicity, and use of translated or culturally adapted PROMs. If provided, the clinical trial registration page for the study was evaluated. Descriptive statistics were used to describe the frequency of each variable.Fifty-four published texts were evaluated. Participant language was reported in four (7%) of the published texts and six (11%) when including the clinical trial registration information. Of the published texts, one (2%) reported ethnic group/race data and 40 (74%) used PROMs. Of those using PROMs, eight (20%) of 40 reported the use of translated PROMs, and three (8%) of 40 reported the use of culturally adapted PROMs.There is a lack of reporting of linguistic, racial, and ethnic data and inconsistent use of PROMs, particularly those that are translated and culturally adapted, in studies included in the American Academy of Orthopaedic Surgeons CPG for distal radius fractures. As sociocultural characteristics and PROMs are associated with outcomes, ensuring they are broadly represented in studies, may improve equity and shared decision-making.Greater inclusion and reporting of demographic data and PROMs are required in musculoskeletal studies to ensure broad applicability and advance health equity.

  View details for DOI 10.1016/j.jhsa.2024.03.015

  View details for PubMedID 38739072

• Implementation of an electronic health record system during global surgical outreach: A prospective evaluation of success and sustainability. World journal of surgery Gatto, A. P., Atkin, D., Tapia, J. C., Lowenberg, M., Kamal, R. N., Shapiro, L. M. 2024

  Abstract

  The burden of musculoskeletal conditions continues to grow in low- and middle-income countries. Among thousands of surgical outreach trips each year, few organizations electronically track patient data to inform real-time care decisions and assess trip impact. We report the implementation of an electronic health record (EHR) system utilized at point of care during an orthopedic surgical outreach trip.In March 2023, we implemented an EHR on an orthopedic outreach trip to guide real-time care decisions. We utilized an effectiveness-implementation hybrid type 3 design to evaluate implementation success. Success was measured using outcomes adopted by the World Health Organization, including acceptability, appropriateness, feasibility, adoption, fidelity, and sustainability. Clinical outcome measures included adherence to essential quality measures and follow-up numerical rating system (NRS) pain scores.During the 5-day outreach trip, 76 patients were evaluated, 25 of which underwent surgery beforehand. The EHR implementation was successful as defined by: mean questionnaire ratings of acceptability (4.26), appropriateness (4.12), feasibility (4.19), and adoption (4.33) at least 4.00, WHO behaviorally anchored rating scale ratings of fidelity (6.8) at least 5.00, and sustainability (80%) at least 60% follow-up at 6 months. All clinical quality measures were reported in greater than 80% of cases with all measures reported in 92% of cases. NRS pain scores improved by an average of 2.4 points.We demonstrate successful implementation of an EHR for real-time clinical use on a surgical outreach trip. Benefits of EHR utilization on surgical outreach trips may include improved documentation, minimization of medical errors, and ultimately improved quality of care.

  View details for DOI 10.1002/wjs.12201

  View details for PubMedID 38730536

• Are Orthopaedic Clinical Trials Linguistically and Culturally Diverse? A Systematic Review JBJS REVIEWS Julian, K. R., Mulakaluri, A., Truong, N. M., Fernandez, A., Kamal, R. N., Shapiro, L. M. 2024; 12 (5)

  View details for DOI 10.2106/JBJS.RVW.24.00012

  View details for Web of Science ID 001225919300001

• Are Orthopaedic Clinical Trials Linguistically and Culturally Diverse? A Systematic Review. JBJS reviews Julian, K. R., Mulakaluri, A., Truong, N. M., Fernandez, A., Kamal, R. N., Shapiro, L. M. 2024; 12 (5)

  Abstract

  Underrepresentation and misrepresentation of historically underrepresented populations in randomized controlled trials (RCTs) may have implications for the validity of research results and their application for diverse populations. To evaluate the representation of historically linguistically, racially, and ethnically underrepresented participants in orthopaedic randomized controlled trials (RCTs) and to assess the use of translated and culturally adapted patient reported outcome measures (PROMs).Separate and comprehensive literature searches of PubMed, Web of Science, and Embase databases were performed to identify RCTs utilizing PROMs between the years 2012 - 2022 among the top five highest 5-year impact factor orthopaedic journals according to the 2021 Journal Citation Reports database. The primary outcomes of interest included reporting of linguistic, racial and ethnic demographic characteristics of trial participants and the utilization of translated PROMs. The methodological quality of each clinical trial was assessed using the Jadad Criteria.230 RCTs met inclusion criteria. The language of participants was reported in 14% of trials and in 17% of trials when searching both the published text and clinical trial registration information. In addition, race and/or ethnicity was reported in 11% of trials, and the use of translated PROMs was reported in 7% of trials. Among the six multinational studies, none reported the language of the study population nor the use of translated PROMs. Notably, four studies (2%) reported utilizing culturally adapted PROMs. The average Jadad score was 3.07.Participant language, race, and ethnicity are infrequently reported in orthopaedic clinical trials, potentially limiting the application and interpretation of study results. Similarly, the linguistic and cultural adaptation of PROMs utilized are often not reported, which also limits interpretations of the validity and generalizability of orthopedic study results. Researchers and journals should promote standard reporting of demographic data and methods of PROM adaptation to ensure results are generalizable to diverse patient populations.III.

  View details for DOI 10.2106/JBJS.RVW.24.00012

  View details for PubMedID 39021638

  View details for PubMedCentralID PMC11250675

• Site of Service Disparities Exist for Total Joint Arthroplasty ORTHOPEDICS Truong, N. M., Leversedge, C., Zhuang, T., Shapiro, L. M., Whittaker, M., Kamal, R. N. 2024; 47 (3): 179-184

  Abstract

  The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes.We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models.We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures.Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

  View details for DOI 10.3928/01477447-20240304-01

  View details for Web of Science ID 001229126100002

  View details for PubMedID 38466828

• Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears. Journal of hand and microsurgery Ku, S., Zhuang, T., Shapiro, L. M., Richard, M. J., Ruch, D. S., Kamal, R. N. 2024; 16 (1): 100009

  Abstract

  While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability.We created a decision tree to compare the following strategies from a healthcare payer perspective: immediate arthroscopic debridement versus immobilization for 4 or 6 weeks with late debridement as needed. Costs were obtained from the Centers for Medicaid and Medicare Services and a national administrative claims database. Probabilities and health-related quality-of-life measures were obtained from published sources. We conducted sensitivity analyses on model inputs, including a probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations.Immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases was both the least costly and most effective strategy. Immediate arthroscopic debridement became cost-effective when success rates of immobilization for 4 or 6 weeks were less than 7.7 or 10.5%, respectively. Our probabilistic sensitivity analysis showed that immobilization for 6 weeks was preferred 97.6% of the time, and immobilization for 4 weeks was preferred 2.4% of the time.Although various early and late debridement strategies can be used to treat superficial TFCC tears without DRUJ instability, immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases is the optimal strategy from a cost-effectiveness standpoint.

  View details for DOI 10.1055/s-0042-1757179

  View details for PubMedID 38854387

  View details for PubMedCentralID PMC11127526

• Orthopedic surgery in Palau-Current capacity, needs, and future directions. World journal of surgery Snyder, E. M., Withy, K., Dever, G., Decherong, C., Adelbai-Fraser, M., Mekoll, N., Uherbelau, G., Kamal, R. N., Shapiro, L. M. 2024

  Abstract

  BACKGROUND: Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality.METHODS: Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n=6). Results were reported descriptively.RESULTS: Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n=3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs.CONCLUSIONS: This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

  View details for DOI 10.1002/wjs.12111

  View details for PubMedID 38393308

• Bone Graft Substitutes-What Are My Options? Hand clinics Shah, K. N., Kamal, R. N. 2024; 40 (1): 13-23

  Abstract

  We examine the range of available bone graft substitutes often used in nonunion and malunion surgery of the upper extremity. Synthetic materials such as calcium sulfate, beta-calcium phosphate ceramics, hydroxyapatite, bioactive glass, and 3D printed materials are discussed. We delve into the advantages, disadvantages, and clinical applications for each, considering factors such as biocompatibility, osteoconductivity, mechanical strength, and resorption rates. This review provides upper extremity surgeons with insights into the available array of bone graft substitutes. We hope that the reviews helps in the decision-making process to achieve optimal outcomes when treating nonunion and malunion of the upper extremity.

  View details for DOI 10.1016/j.hcl.2023.09.001

  View details for PubMedID 37979985

• Equitable Integration of Patient-Reported Outcomes Into Clinical Practice-Opportunities, Challenges, and a Roadmap for Implementation. The Journal of the American Academy of Orthopaedic Surgeons Shapiro, L. M., Katz, P., Stern, B. Z., Kamal, R. N. 2024

  Abstract

  Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical care to complement objective functional measures (eg, range of motion) and are increasingly integrated to guide treatment decisions and predict outcomes. In some situations, when PROMs are used during clinical care they can improve patient mortality, outcomes, engagement, well-being, and patient-physician communication. Guidance on how PROMs should be communicated with patients continued to be developed. However, PROM use may have unintended consequences, such as when used implemented without accounting for confounding factors (eg, psychological and social health) or in perpetuating healthcare disparities when used imprecisely (eg, lack of linguistic or cultural validation). In this review, we describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap to support orthopaedic surgery practices in incorporating PROMs into routine care to equitably improve patient health.

  View details for DOI 10.5435/JAAOS-D-23-00798

  View details for PubMedID 38194644

• AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors. The Journal of bone and joint surgery. American volume Ring, D., Adams, J., Samora, J., Kamal, R. 2024

  Abstract

  Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.

  View details for DOI 10.2106/JBJS.23.00784

  View details for PubMedID 38194597

• Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series Schultz, E. A., Gomez, G. I., Gardner, M., Hu, S., Safran, M., Amanatullah, D., Shapiro, L. M., Kamal, R. N. 2024

  View details for DOI 10.1097/CORR.0000000000003325

• Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA network open Welch, J. M., Gomez, G. I., Chatterjee, M., Shapiro, L. M., Morris, A. M., Gardner, M. J., Sox-Harris, A. H., Baker, L., Koltsov, J. C., Castillo, T., Giori, N., Salyapongse, A., Kamal, R. N. 2023; 6 (12): e2347834

  Abstract

  Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

  View details for DOI 10.1001/jamanetworkopen.2023.47834

  View details for PubMedID 38100104

• Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study. Journal of hand and microsurgery Shapiro, L. M., Xiao, M., Zhuang, T., Ruch, D. S., Richard, M. J., Kamal, R. N. 2023; 15 (5): 351-357

  Abstract

  Objective  To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods  We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results  The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p  < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p  < 0.01). Conclusion  The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

  View details for DOI 10.1055/s-0042-1749460

  View details for PubMedID 38152674

  View details for PubMedCentralID PMC10751197

• The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips. Journal of hand and microsurgery Shapiro, L. M., Chang, J., Fox, P. M., Kozin, S., Chung, K. C., Dyer, G. S., Fufa, D., Leversedge, F., Katarincic, J., Kamal, R. 2023; 15 (5): 358-364

  Abstract

  Background  The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods  We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results  In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion  This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

  View details for DOI 10.1055/s-0042-1749465

  View details for PubMedID 38152677

  View details for PubMedCentralID PMC10751199

• The Safety of the Volar Intraarticular Extended Window (VIEW) Approach for Intra-articular Distal Radius Fractures. Hand (New York, N.Y.) Kamal, R. N., Gomez, G. I., Schultz, E. A., Shapiro, L. M. 2023: 15589447231210926

  Abstract

  A novel volar approach to intra-articular distal radius fractures has been introduced for treatment of intra-articular distal radius fractures, in which volar extrinsic ligaments are released to create a volar window into the radiocarpal joint (Volar Intraarticular Extended Window [VIEW] approach). Our purpose was to evaluate the safety of VIEW approach for treatment of intra-articular distal radius fractures.A retrospective chart review was performed for 13 patients with intra-articular distal radius fractures treated operatively with the VIEW surgical technique using an intra-articular window in the volar capsule to aid in reduction and fixation. Postoperative radiographs were reviewed to assess for ulnocarpal translocation by assessing lunate uncovering and radial-carpal distance.Thirteen patients were treated with the VIEW approach with mean follow-up of 28 weeks (range, 7-67 weeks; SD, 18 weeks). The mean postoperative lunate uncovering was 34.6% (SD, 7.7%) and mean radial-carpal distance was 4.6 mm (SD, 1.5 mm). Postoperatively, mean intra-articular step-off was 0.9 mm (SD, 1.2 mm) and mean intra-articular gap was 1.2 mm (SD, 1.0 mm). No patients reported clinical symptoms of wrist instability.Using the VIEW approach during a volar approach to intra-articular distal radius fractures is safe and does not lead to carpal instability. Surgeons can consider using the approach when direct visualization of the articular surface may be beneficial for reduction or fixation.Therapeutic IV.

  View details for DOI 10.1177/15589447231210926

  View details for PubMedID 38006231

• Volar Intra-articular Extended Window Approach for Intra-articular Distal Radius Fractures. Techniques in hand & upper extremity surgery Kamal, R. N., Bronenberg, P., Shapiro, L. M. 2023

  Abstract

  Distal radius fractures are one of the most common injuries seen globally with increasing use of use of volar plating for surgical treatment. Although it is common to directly visualize the articular surface for most other periarticular fractures, during volar plating of the distal radius the joint is typically not visualized. This is due to concern for carpal instability from disruption of the volar carpal ligaments. When direct visualization of the articular surface is deemed necessary, either to reduce articular fragments or to confirm the quality of reduction, current options include a separate dorsal arthrotomy or arthroscopic assistance. However, biomechanical evidence supports safely performing a volar capsulotomy to visualize the articular surface. We describe the Volar Intra-Articular Extended Window approach, which allows direct visualization of the articular surface through the volar approach to treat distal radius fractures.

  View details for DOI 10.1097/BTH.0000000000000463

  View details for PubMedID 37994780

• Can Caregivers Forecast Their Child's Postoperative Disability After Elective Orthopedic Surgery? Cureus Baskar, D., Mehta, S., Freiman, H., Segovia, N. A., Vuong, B. B., Richey, A., Langner, J. L., Hastings, K. G., Kamal, R. N., Frick, S. 2023; 15 (11): e48575

  Abstract

  Background While there has been a growing emphasis on evaluating the patient's perspective of health outcomes, caregiver expectations of post-orthopedic procedure disability and pain in a pediatric population are yet to be investigated. This study evaluates whether caregivers' preoperative expectations of pain and function differ from their child's early outcomes after surgical orthopedic intervention. Methodology Patients eight to 18 years old undergoing elective orthopedic surgery were enrolled. The caregivers of consented patients completed a survey at the child's preoperative appointment to predict their postoperative pain and disability. The child was given the same survey during their postoperative visit four to six weeks after surgery to assess actual levels of functioning following the procedure. Scores were analyzed to study correlations between patient and caregiver responses (n = 48). Results Caregivers underestimated their child's postoperative psychosocial functioning, as evidenced by the Psychosocial Health Summary Score, and overestimated pain, as demonstrated by the Numeric Pain Rating Scale. The Pediatric Quality of Life Inventory scores showed caregivers had differing expectations of the impact surgery had across various aspects of the physical, emotional, social, and school functioning domains. Higher parental pain catastrophizing was associated with underestimated predictions of their child's psychosocial functioning after surgery. No significant difference was found in the patient's physical functioning, as shown by the Physical Health Summary Score. Conclusions Surgical intervention is a major event that can provoke anxiety for parents and caregivers. Understanding differences in caregiver perspectives and early postoperative patient outcomes provides physicians valuable insights. Explaining to caregivers that patient psychosocial factors and functional outcomes after surgery are commonly better than expected can alleviate anxiety and prevent catastrophizing. This knowledge can help guide caregiver expectations and plans for their child's postoperative pain control and functional recovery.

  View details for DOI 10.7759/cureus.48575

  View details for PubMedID 38073935

  View details for PubMedCentralID PMC10710311

• Enhanced Approaches to the Treatment of Distal Radius Fractures. Hand clinics Patel, D., Kamal, R. 2023; 39 (4): 515-521

  Abstract

  Distal radius fractures are among the most common fractures treated by orthopedic surgeons. Various classification systems have been described which can help in deciding the approach for fixation. In some cases, a computed tomography scan can provide better understanding of the fracture fragments and displacement for surgical planning. Plating through the volar approach is the most common approach for fractures meeting operative criteria. Several additional approaches can be used for specific fracture patterns. These approaches can be used in isolation or in conjunction with other approaches to aid in visualization and fixation.

  View details for DOI 10.1016/j.hcl.2023.07.001

  View details for PubMedID 37827604

• Strategies for Perioperative Optimization in Upper Extremity Fracture Care. Hand clinics Zhuang, T., Kamal, R. N. 2023; 39 (4): 617-625

  Abstract

  Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

  View details for DOI 10.1016/j.hcl.2023.05.009

  View details for PubMedID 37827614

• Innovation in Upper Extremity Fracture Treatment-Implementation of Advanced Techniques to Improve Outcomes. Hand clinics Kamal, R. N., Shapiro, L. M. 2023; 39 (4): xi

  View details for DOI 10.1016/j.hcl.2023.07.002

  View details for PubMedID 37827616

• Upper extremity trauma in Costa Rica - Evaluating epidemiology and identifying opportunities CURRENT ORTHOPAEDIC PRACTICE Appiani, L., Castro, S., Romero, B., Salas, J., Vindas, P., Soto, R., Artavia, C., Kamal, R. N., Shapiro, L. M. 2023; 34 (6): 280-284

  View details for DOI 10.1097/BCO.0000000000001233

  View details for Web of Science ID 001124056300006

• Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance? The Journal of arthroplasty Chakraborty, A., Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Kamal, R. N. 2023

  Abstract

  Disparities in access to care based on insurance type exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus non-operative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 vs. 10.9 or 12.0%, respectively; P<0.0001) and had longer times to surgery (297 vs. 215 or 261 days, respectively; P<0.0001) compared to Medicare Advantage and commercially insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (Odds Ratio (OR) = 0.62 [95% Confidence Intervals (CI): 0.60-0.64] vs. Medicare Advantage, OR = 0.63 [95% CI: 0.61-0.64] vs. commercial) or NOI (OR = 0.92 [95% CI: 0.91-0.94] vs. Medicare Advantage, OR = 0.81 [95% CI: 0.79-0.82] vs. commercial).Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially insured patients. Further investigation into the causes of these disparities, such as patient costs or access barriers, is necessary to ensure equitable care.

  View details for DOI 10.1016/j.arth.2023.09.029

  View details for PubMedID 37778640

• Preoperative Optimization for Orthopaedic Surgery: Steps to Reduce Complications. The Journal of the American Academy of Orthopaedic Surgeons Shapiro, L. M., Bolognesi, M. P., Bozic, K., Kamal, R. N. 2023

  Abstract

  As the population ages and patients maintain higher levels of activity, the incidence of major and minor orthopaedic procedures continues to rise. At the same time, health policies are incentivizing efforts to improve the quality and value of musculoskeletal health services. As such, orthopaedic surgeons play a key role in directing the optimization of patients before surgery by assessing patient risk factors to inform risk/benefit discussions during shared decision-making and designing optimization programs to address modifiable risks. These efforts can lead to improved health outcomes, reduced costs, and preference-congruent treatment decisions. In this review, we (1) summarize the evidence on factors known to affect outcomes after common orthopaedic procedures, (2) identify which factors are considered modifiable and amenable to preoperative intervention, and (3) provide guidance for preoperative optimization.

  View details for DOI 10.5435/JAAOS-D-22-00192

  View details for PubMedID 37769027

• Upper Extremity Trauma in Costa Rica - Evaluating Epidemiology and Identifying Opportunities. Current orthopaedic practice Castro Appiani, L. M., Castro, S., Romero, B., Díaz Salas, J. D., Vindas, P., Soto, R., Artavia, C. C., Kamal, R., Shapiro, L. M. 2023; 34 (6): 280-284

  Abstract

  Traffic accidents and musculoskeletal injuries represent a major cause of morbidity and mortality in Costa Rica. To inform capacity building efforts, we conducted a survey study of hand and upper extremity (UE) fellowship-trained surgeons in Costa Rica to evaluate the epidemiology, complications, and challenges in care of UE trauma.Aiming to capture all hand and UE trained surgeons in Costa Rica, we compiled a list of nine surgeons and sent a survey in Spanish using Qualtrics. Assessment questions were developed to understand the burden, complications, practice patterns, challenges, and capacity associated with care of UE trauma. Questions were designed to focus on opportunities for future investigation. Questions were translated and adapted by two bilingual speakers. Data were reported descriptively and open-ended responses were analyzed using content analysis.Nine (100%) surgeons completed the survey. Distal radius fractures, hand and finger fractures, and tendon injuries are the most frequently noted conditions. Stiffness and infection are the most common complications. About 29% of patients are unable to get necessary therapy and 13% do not return for follow-up care with monetary, distance, and transportation limitations being the greatest challenges.The burden of UE trauma in Costa Rica is high. Identifying common conditions, complications, challenges, and capacity allows for a tailored approach to partnership and capacity building (e.g. directing capacity building and/or research infrastructure toward distal radius fractures). These insights represent opportunities to inform community-driven care improvement and research initiatives, such as Delphi consensus approaches to identify priorities or the development of outcome measurement systems.

  View details for DOI 10.1097/bco.0000000000001233

  View details for PubMedID 38404621

  View details for PubMedCentralID PMC10888422

• Does time to surgery for distal radius fractures impact clinical and radiographic outcomes? A systematic literature review CURRENT ORTHOPAEDIC PRACTICE Julian, K. R., Truong, N. M., Leversedge, C., Kwong, J. W., Rosinski, A., Kamal, R. N., Shapiro, L. M. 2023; 34 (5): 229-235

  View details for DOI 10.1097/BCO.0000000000001224

  View details for Web of Science ID 001059109300004

• Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips. The Journal of hand surgery Almeida, B. A., Kerluku, J., Shapiro, L. M., Kamal, R., Fufa, D. T. 2023

  Abstract

  PURPOSE: As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation.METHODS: We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts.RESULTS: A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts.CONCLUSIONS: Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs.CLINICAL RELEVANCE: Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.

  View details for DOI 10.1016/j.jhsa.2023.06.014

  View details for PubMedID 37656068

• Is There a Critical Dorsal Lunate Facet Size in Distal Radius Fractures That Leads to Dorsal Carpal Subluxation? A Biomechanical Study of the Dorsal Critical Corner. The Journal of hand surgery Shapiro, L. M., Zhou, J., Shah, K., Frey, C., Chan, C., Kamal, R. N. 2023

  Abstract

  Intra-articular distal radius fractures are common and can be associated with carpal instability. Failure to address articular fragments linked to maintaining carpal stability can lead to radiocarpal subluxation or dislocation. The purpose of this study was to evaluate the size of a dorsal osteotomy in the dorsal/volar plane of the lunate facet that leads to dorsal carpal subluxation.Dorsal lunate facet fractures were simulated twice in each of nine fresh-frozen cadavers. After completing a partial dorsal osteotomy in the radial/ulnar plane between the scaphoid and lunate facets, an osteotomy in the dorsal/volar plane was completed. Using a cutting jig, first an estimated 5-mm osteotomy, and then a 10-mm osteotomy (from the dorsal rim of the distal radius) were completed. The wrist was mounted in a custom jig and loaded with 100 N. Displacement of the lunate in the dorsal/volar plane compared with displacement in an intact specimen was evaluated and used to assess carpal subluxation.Lunate translation was 0 mm ± 0 mm in the intact state. The 5-mm osteotomy averaged 29% of the distal radius dorsal lunate facet in the dorsal/volar plane, and lunate translation was 0.7 mm ± 1.7 mm. The 10-mm osteotomy averaged 54% of the dorsal lunate facet in the dorsal/volar plane, and lunate translation was 2.8 mm ± 2.6 mm. Assuming a linear relationship from the osteotomies created, an osteotomy of an estimated ≥40% of the distal radius in the dorsal to volar plane resulted in substantial dorsal subluxation, although this specific osteotomy was not assessed in our study.Sequentially increased dorsal osteotomies of the dorsal lunate facet result in increased dorsal carpal subluxation.Distal radius fractures that include >40% of the "dorsal critical corner" are at risk for dorsal carpal subluxation and may require supplementary fixation.

  View details for DOI 10.1016/j.jhsa.2023.07.001

  View details for PubMedID 37589617

• Response to "Letter Regarding 'The Volar Intra-Articular Extended Window Approach for Intra-Articular Distal Radius Fractures'". The Journal of hand surgery Kamal, R. N., Ostergaard, P. J., Shapiro, L. M. 2023; 48 (8): e7

  View details for DOI 10.1016/j.jhsa.2023.04.011

  View details for PubMedID 37536879

• Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. Journal of general internal medicine Harris, A. H., Finlay, A. K., Hagedorn, H. J., Manfredi, L., Jones, G., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Pershing, S., Mudumbai, S. 2023

  Abstract

  BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.DESIGN: Qualitative study of semi-structured telephone interviews.PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

  View details for DOI 10.1007/s11606-023-08287-0

  View details for PubMedID 37407767

• Lack of alignment between orthopaedic surgeon priorities and patient expectations in total joint arthroplasty. Patient safety in surgery Shah, H. N., Barrett, A. A., Le, P. H., Arora, P., Kamal, R. N., Amanatullah, D. F. 2023; 17 (1): 17

  Abstract

  Healthcare systems are shifting toward "patient-centered" care often without assessing the values important to patients. Analogously, the interests of the patient may be disparate with physician interests, as pay-for-performance models become common. The purpose of the study was to determine which medical preferences are essential for patients during their surgical care.This prospective, observational study surveyed 102 patients who had undergone a primary knee replacement and/or hip replacement surgery about hypothetical scenarios regarding their surgical experience. Data analysis included categorical variables presented as a number and percent, while continuous variables presented as mean and standard deviation. Statistical analysis for anticoagulation data included the Pearson chi-square test and one-way ANOVA test.A large majority, 73 patients (72%), would not pay to have a four-centimeter or smaller incision. The remaining 29 patients (28%) would prefer to have a four-centimeter or smaller incision and would pay a mean of $1,328 ± 1,629 for that day. A significant number of patients preferred not to use anticoagulation (p = 0.019); however, the value attributed to avoiding a specific method of anticoagulation was found not to be significant (p = 0.507).The study determined the metrics prioritized by hospitals and surgeons are not important to the majority of patients when they evaluate their own care. These disconnects in the entitlements patients expect and receive can be solved by including patients in discussions with physicians and hospital systems.

  View details for DOI 10.1186/s13037-023-00365-w

  View details for PubMedID 37386583

  View details for PubMedCentralID PMC10308647

• Is Outpatient Spine Surgery Associated with New, Persistent Opioid Use in Opioid-Naïve Patients? A Retrospective National Claims Database Analysis. The spine journal : official journal of the North American Spine Society Schultz, E., Zhuang, T., Shapiro, L. M., Hu, S. S., Kamal, R. N. 2023

  Abstract

  Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting.To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures.Retrospective analysis using national administrative claims database.390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery.Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users.We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors.19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval (CI): 0.69, 0.73], p < 0.001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < 0.001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < 0.001) were lower in the outpatient cohort compared to the inpatient.Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification.Level III Prognostic Study.We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

  View details for DOI 10.1016/j.spinee.2023.06.391

  View details for PubMedID 37355048

• Capacity Assessment Tool to Promote Capacity Building in Global Orthopaedic Surgical Outreach. The Journal of bone and joint surgery. American volume Shapiro, L. M., Welch, J., Leversedge, C., Katarincic, J. A., Leversedge, F. J., Dyer, G. S., Kozin, S. H., Fox, P. M., McCullough, M., Agins, B., Kamal, R. N. 2023

  Abstract

  A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building.To develop the CAT-os tool, we utilized methodological triangulation-an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking.The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity).The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

  View details for DOI 10.2106/JBJS.23.00020

  View details for PubMedID 37319177

• Does Time to Surgery for Distal Radius Fractures Impact Clinical and Radiographic Outcomes? A Systematic Literature Review. Current orthopaedic practice Julian, K. R., Truong, N. M., Leversedge, C., Kwong, J. W., Rosinski, A., Kamal, R. N., Shapiro, L. M. 2023; 34 (5): 229-235

  Abstract

  Distal radius fractures are one of the most common upper extremity fractures across all age groups. Although the American Academy of Orthopaedic Surgery (AAOS) Clinical Practice Guidelines have defined recommendations for the treatment of distal radius fractures, the optimal time to surgery was not included. There remains relatively little guidance or consensus regarding the optimal timing of surgical intervention for distal radius fractures and the impact of time to surgery on outcomes. As such, the purpose of this investigation is to systematically review clinical and radiographic outcomes associated with time to surgical management of distal radius fractures.

  View details for DOI 10.1097/bco.0000000000001224

  View details for PubMedID 38264709

  View details for PubMedCentralID PMC10802167

• Are Patient-Reported Outcome Measures for Distal Radius Fractures Validated for Spanish and Culture? A Systematic Review. The Journal of hand surgery Lemos, J., Xiao, M., Castro Appiani, L. M., Katz, P., Kamal, R. N., Shapiro, L. M. 2023

  Abstract

  Patient-reported outcome measures (PROMs) are used commonly to assess function to direct treatment and evaluate outcomes for patients with distal radius fractures. Most PROMs have been developed and validated in English with minimal report of the demographics of patients studied. The validity of applying these PROMs among Spanish-speaking patients is unknown. The purpose of this study was to evaluate the quality and psychometric properties of Spanish-language adaptations of PROMs for distal radius fractures.We conducted a systematic review to identify published studies of adaptations of Spanish-language PROMs evaluating patients with distal radius fractures. We evaluated the methodologic quality of the adaptation and validation using Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaire, and the COnsensus-based Standards for the selection of health Measurement INstruments Checklist for Cross-Cultural Validity. The level of evidence was evaluated based upon prior methodology.Five instruments reported in eight studies were included: the Patient-Rated Wrist Evaluation (PRWE), Disability of Arm Shoulder and Hand, Upper Limb Functional Index, Lawton Instrumental Activities of Daily Living Scale, and Short Musculoskeletal Function Assessment. The PRWE was the most frequently included PROM. No study followed all six processes for adaptation or assessed all measurement properties. No study demonstrated the completion of more than eight of the 14 aspects of cross-cultural validity. The PRWE had moderate evidence to support half of the domains of measurement properties evaluating the level of evidence.None of the five instruments identified received a good rating on all three checklists. Only the PWRE demonstrated moderate evidence on half of the measurement domains.Given the lack of strong evidence to support the quality of these instruments, we recommend adaptation and testing of PROMs for this population before use. Currently, PROMs in Spanish-speaking patients should be used with caution so as not to perpetuate health care disparities.

  View details for DOI 10.1016/j.jhsa.2023.03.017

  View details for PubMedID 37191603

• Decision Making and Cost in Healthcare: The Patient Perspective. Journal of surgical orthopaedic advances Lindsay, S. E., Alokozai, A., Eppler, S. L., Yao, J., Morris, A., Kamal, R. N. 2023; 32 (1): 23-27

  Abstract

  Unsustainable spending and unsatisfactory outcomes have prompted a reanalysis of healthcare policy towards value. Several strategies have been proposed as part of this effort including cost sharing plans to shift costs to patients and gain-sharing models to shift risk to health systems. The patient perspective is rarely elicited in policy formation despite efforts to increase patient-centered care. We conducted a prospective study of 118 patients presenting to hand clinic to assess patient perspective of who should constrain treatment options (patient, physician, insurance company, hospital) and be responsible for costs in scenarios of clinical equipoise. We found that patients believed that insurance companies and hospitals should not constrain which treatment options are available to a patient and that physicians and patients should together influence the availability of treatment options. Patients were willing to cost share with insurance companies when choosing more expensive treatments or in the setting of non-life-threatening diseases. In addressing rising healthcare costs, patient perspectives can inform policies designed to increase value. Asking patients to cost share when choosing a more expensive treatment option in the setting of clinical equipoise could be a strategy for health systems to increase value. Level of Evidence: III (Journal of Surgical Orthopaedic Advances 32(1):023-027, 2023).

  View details for PubMedID 37185073

• Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18-64 Years and ≥65 Years by Insurance Type. The Journal of hand surgery Tankersley, M. P., Zhuang, T., Julian, K., Fernandez, A., Kamal, R. N., Shapiro, L. M. 2023

  Abstract

  Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures.We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities.In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR] = 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR = 1.38 [95% CI, 1.25-1.53]).Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion.In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.

  View details for DOI 10.1016/j.jhsa.2023.03.003

  View details for PubMedID 37029034

• The Volar Intra-Articular Extended Window Approach for Intra-Articular Distal Radius Fractures. The Journal of hand surgery Kamal, R. N., Ostergaard, P. J., Shapiro, L. M. 2023

  Abstract

  The number of distal radius fractures treated surgically is increasing, with the volar Henry approach most commonly used. Traditionally, to directly visualize intra-articular fracture reductions, a dorsal approach is also used, which can lead to increased morbidity and operative time. We describe the volar intra-articular extended window approach for intra-articular distal radius fractures, which allows direct visualization of fracture reduction from the same volar approach to the distal radius. The volar intra-articular extended window approach is performed by creating a capsulotomy in the volar wrist capsule between the long and short radiolunate ligaments while maintaining the integrity of the short radiolunate ligament to prevent postoperative carpal instability. Using this approach allows the surgeon to directly visualize the radiocarpal joint to assess reduction and ensure that no screws are placed intra-articular.

  View details for DOI 10.1016/j.jhsa.2022.09.018

  View details for PubMedID 36822989

• Equity-Driven Implementation of Patient-Reported Outcome Measures in Musculoskeletal Care: Advancing Value for All. The Journal of bone and joint surgery. American volume Stern, B. Z., Franklin, P. D., Shapiro, L. M., Chaudhary, S. B., Kamal, R. N., Poeran, J. 2023

  Abstract

  ABSTRACT: The clinical use of patient-reported outcome measures (PROMs) in musculoskeletal care is expanding, encompassing both individual patient management and population-level applications. However, without thoughtful implementation, we risk introducing or exacerbating disparities in care processes or outcomes. We outline examples of opportunities, challenges, and priorities throughout PROM implementation to equitably advance value-based care at both the patient and population level. Balancing standardization with tailored strategies can enable the large-scale implementation of PROMs while optimizing care processes and outcomes for all patients.

  View details for DOI 10.2106/JBJS.22.01016

  View details for PubMedID 36728450

• Medicaid Insurance is Associated with Treatment Disparities for Proximal Humerus Fractures in a National Database Analysis. Journal of shoulder and elbow surgery Truong, N. M., Zhuang, T., Leversedge, C., Ma, C. B., Kamal, R. N., Shapiro, L. M. 2022

  Abstract

  BACKGROUND: Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs.METHODS: We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010-2019 were identified by ICD-9/10 diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, non-infectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications.RESULTS: We included 245,396 patients for analysis. 14% of Medicaid patients (1,789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately-insured patients and 16% (13,305/83,068) of Medicare patients (pairwise p < 0.001). TTS (Medicaid: 11.7 days, private: 10.6 days (p < 0.001), Medicare: 10.7 days (p = 0.003)) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio [OR]: 0.77 [95% confidence interval (CI): 0.63 - 0.93] for private vs Medicaid, and 0.71 [95% CI: 0.59 - 0.88] for Medicare vs Medicaid) and experienced fewer 90-day postoperative complications (adjusted ORs: 0.73 [95% CI: 0.62 - 0.85] for private vs Medicaid, 0.65 [95% CI: 0.55 - 0.77] for Medicare vs Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications.CONCLUSION: There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality-improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers patients face and minimize healthcare inequities seen in the treatment of PHFs based on insurance type.

  View details for DOI 10.1016/j.jse.2022.11.016

  View details for PubMedID 36581135

• The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System? Clinical orthopaedics and related research Zhuang, T., Shapiro, L. M., Baker, L. C., Kamal, R. N. 2022

  Abstract

  BACKGROUND: Price variations in healthcare can be caused by quality or factors other than quality such as market share, negotiating power with insurers, or hospital ownership model. Efforts to improve care value (defined as the ratio between health outcomes and price) by making healthcare prices readily accessible to patients are driven by the assumption this can help patients more easily identify high-quality, low-price clinicians and health systems, thus reducing price variations. However, if price variations are driven by factors other than quality, then strategies that involve payments for higher-quality care are unlikely to reduce price variation and improve value. It is unknown whether prices for total joint arthroplasty (TJA) are correlated with the quality of care or whether factors other than quality are responsible for price variation.QUESTIONS/PURPOSES: (1) How do prices insurers negotiate for TJA paid to a single, large health system vary across payer types? (2) Are the mean prices insurers negotiate for TJA associated with hospital quality?METHODS: We analyzed publicly available data from 22 hospitals in a single, large regional health system, four of which were excluded owing to incomplete quality information. We chose to use data from this single health system to minimize the confounding effects of between-hospital reputation or branding and geographic differences in the cost of providing care. This health system consists of large and small hospitals serving urban and rural populations, providing care for more than 3 million individuals. For each hospital, negotiated prices for TJA were classified into five payer types: commercial in-network, commercial out-of-network, Medicare Advantage (plans to which private insurers contract to provide Medicare benefits), Medicaid, and discounted cash pay. Traditional Medicare plans were not included because the prices are set statutorily, not negotiated. We obtained hospital quality measures from the Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services quality measures included TJA-specific complication and readmission rates in addition to hospital-wide patient survey star rating (measure of patient care experience) and total performance scores (aggregate measure of clinical outcomes, safety, patient experience, process of care, and efficiency). We evaluated the association between the mean negotiated hospital prices and Centers for Medicare and Medicaid Services quality measures using Pearson correlation coefficients and Spearman rho across all payer types. Statistical significance was defined as p < 0.0025.RESULTS: The mean ± SD overall negotiated price for TJA was USD 54,500 ± 23,200. In the descriptive analysis, the lowest negotiated prices were associated with Medicare Advantage (USD 20,400 ± 1800) and Medicaid (USD 20,300 ± 8600) insurance plans, and the highest prices were associated with out-of-network care covered by commercial insurance plans (USD 78,800 ± 9200). There was no correlation between the mean negotiated price and TJA complication rate (discounted cash price: r = 0.27, p = 0.29; commercial out-of-network: r = 0.28, p = 0.26; commercial in-network: r = -0.07, p = 0.79; Medicare Advantage: r = 0.11, p = 0.65; Medicaid: r = 0.03, p = 0.92), readmission rate (discounted cash price: r = 0.19, p = 0.46; commercial out-of-network: r = 0.24, p = 0.33; commercial in-network: r = -0.13, p = 0.61; Medicare Advantage: r = -0.06, p = 0.81; Medicaid: r = 0.09, p = 0.74), patient survey star rating (discounted cash price: r = -0.55, p = 0.02; commercial out-of-network: r = -0.53, p = 0.02; commercial in-network: r = -0.37, p = 0.13; Medicare Advantage: r = -0.08, p = 0.75; Medicaid: r = -0.02, p = 0.95), or total hospital performance score (discounted cash price: r = -0.35, p = 0.15; commercial out-of-network: r = -0.55, p = 0.02; commercial in-network: r = -0.53, p = 0.02; Medicare Advantage: r = -0.28, p = 0.25; Medicaid: r = 0.11, p = 0.69) for any of the payer types evaluated.CONCLUSION: There is substantial price variation for TJA that is not accounted for by the quality of care, suggesting that a mismatch between price and quality exists. Efforts to improve care value in TJA are needed to directly link prices with the quality of care delivered, such as through matched quality and price reporting mechanisms. Future studies might investigate whether making price and quality data accessible to patients, such as through value dashboards that report easy-to-interpret quality data alongside price information, moves patients toward higher-value care decisions.CLINICAL RELEVANCE: Efforts to better match the quality of care with negotiated prices such as matched quality and price reporting mechanisms, which have been shown to increase the likelihood of choosing higher-value care in TJA, could improve the value of care.

  View details for DOI 10.1097/CORR.0000000000002489

  View details for PubMedID 36729581

• Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? The Journal of hand surgery Zhuang, T., Shapiro, L. M., Schultz, E. A., Truong, N. M., Harris, A. H., Kamal, R. N. 2022

  Abstract

  PURPOSE: A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG.METHODS: Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release.RESULTS: Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to-0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by-23.57 per 1,000 patients (95% CI,-37.72 to-9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG.CONCLUSIONS: The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS.CLINICAL RELEVANCE: Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

  View details for DOI 10.1016/j.jhsa.2022.09.019

  View details for PubMedID 36460552

• Cost minimization analysis of the treatment of olecranon fracture in elderly patients: a retrospective analysis CURRENT ORTHOPAEDIC PRACTICE Welch, J. M., Zhuang, T., Shapiro, L. M., Gardner, M., Xiao, M., Kamal, R. N. 2022; 33 (6): 559-564

  View details for Web of Science ID 000877219300011

• Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears JOURNAL OF HAND AND MICROSURGERY Ku, S., Zhuang, T., Shapiro, L. M., Richard, M. J., Ruch, D. S., Kamal, R. N. 2022

  View details for DOI 10.1055/s-0042-1757179

  View details for Web of Science ID 000869427700002

• Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist. World journal of surgery Leversedge, C., McCullough, M., Appiani, L. M., Dinh, M. P., Kamal, R. N., Shapiro, L. M. 2022

  Abstract

  INTRODUCTION: While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.METHODS: We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.RESULTS: A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.CONCLUSION: As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

  View details for DOI 10.1007/s00268-022-06760-1

  View details for PubMedID 36210361

• Cost minimization analysis of the treatment of olecranon fracture in elderly patients: a retrospective analysis. Current orthopaedic practice Welch, J. M., Zhuang, T., Shapiro, L. M., Gardner, M. J., Xiao, M., Kamal, R. N. 2022; 33 (6): 559-564

  Abstract

  Operative treatment of olecranon fractures in the elderly can lead to greater complications with similar outcomes to nonoperative treatment. The purpose of this study was to analyze cost differences between operative and nonoperative management of isolated closed olecranon fractures in elderly patients.Using a United States Medicare claims database, the authors identified 570 operative and 1,863 nonoperative olecranon fractures between 2005 and 2014. The authors retrospectively determined cost of treatment from the payer perspective for a 1-year period after initial injury, including any surgical procedure, emergency room care, follow-up care, physical therapy, and management of complications.One year after diagnosis, mean costs per patient were higher for operative treatment (United States dollars [US$]10,694 vs US$2,544). 31.05% of operative cases were associated with a significant complication compared with 4.35% of nonoperative cases. When excluding complications, mean costs per patient were still higher for operative treatment ($7,068 vs $2,320).These findings show that nonoperative management for olecranon fractures in the elderly population leads to fewer complications and is less costly. Nonoperative management may be a higher-value management option for this patient population. These results will help inform management of olecranon fractures as payers shift toward value-based reimbursement models in which quality of care and cost influence surgical decision making.Level IV.

  View details for DOI 10.1097/bco.0000000000001167

  View details for PubMedID 36873608

  View details for PubMedCentralID PMC9977169

• Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioperative medicine (London, England) Harris, A. H., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H. J., Mudumbai, S. 2022; 11 (1): 33

  Abstract

  BACKGROUND: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures.METHODS: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined.RESULTS: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476.CONCLUSIONS: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.

  View details for DOI 10.1186/s13741-022-00265-0

  View details for PubMedID 36096937

• Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA network open Tewari, P., Sweeney, B. F., Lemos, J. L., Shapiro, L., Gardner, M. J., Morris, A. M., Baker, L. C., Harris, A. S., Kamal, R. N. 2022; 5 (9): e2231911

  Abstract

  Importance: Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.Objective: To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.Evidence Review: A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.Findings: Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.Conclusions and Relevance: In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

  View details for DOI 10.1001/jamanetworkopen.2022.31911

  View details for PubMedID 36112373

• A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach. The Journal of bone and joint surgery. American volume Shapiro, L. M., Welch, J. M., Chatterjee, M., Katarincic, J. A., Leversedge, F. J., Dyer, G. S., Fufa, D. T., Kozin, S. H., Chung, K. C., Fox, P. M., Chang, J., Kamal, R. N. 2022

  Abstract

  BACKGROUND: Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs.METHODS: We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs.RESULTS: A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity.CONCLUSIONS: The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.

  View details for DOI 10.2106/JBJS.22.00353

  View details for PubMedID 35984012

• Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis. The Journal of hand surgery Michaud, J. B., Zhuang, T., Shapiro, L. M., Cohen, S. A., Kamal, R. N. 2022

  Abstract

  PURPOSE: Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs.METHODS: Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service.RESULTS: The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs.CONCLUSIONS: Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs.CLINICAL RELEVANCE: To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.

  View details for DOI 10.1016/j.jhsa.2022.06.018

  View details for PubMedID 35985865

• Patient-Derived Framework for Quality inHand Surgery: A Qualitative Analysis. The Journal of hand surgery Park, M. O., Eppler, S. L., Chatterjee, M., Shapiro, L. M., Hand Surgery Quality Consortium, Kamal, R. N., Kamal, R. N., Harris, A. H., Kakar, S., Blazar, P., Akelman, E., Got, C., Ruch, D., Richard, M., Ring, D. 2022

  Abstract

  PURPOSE: Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery.METHODS: Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective.RESULTS: Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care.CONCLUSIONS: Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients.CLINICAL RELEVANCE: The themes identified in this study can inform efforts towards patient-centered quality measure development.

  View details for DOI 10.1016/j.jhsa.2022.06.014

  View details for PubMedID 35963794

• Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis. The Journal of hand surgery Zhuang, T., Michaud, J. B., Shapiro, L. M., Baker, L. C., Welch, J. M., Kamal, R. N. 2022

  Abstract

  PURPOSE: Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges?METHODS: We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges.RESULTS: Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018-$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902-$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges.CONCLUSIONS: Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery.CLINICAL RELEVANCE: Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.

  View details for DOI 10.1016/j.jhsa.2022.06.002

  View details for PubMedID 35927122

• Quality Reporting Windows May Not Capture the Effects of Surgical Site Infections After Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Shapiro, L. M., Graham, L. A., Hawn, M. T., Kamal, R. N. 2022; 104 (14): 1281-1291

  Abstract

  BACKGROUND: Postoperative surgical site infections (SSIs) and the associated complications impact morbidity and mortality and result in substantial burden to the health-care system. These complications are typically reported during the 90-day surveillance period, with implications for reimbursement and quality measurement; however, the long-term effects of SSI are not routinely assessed. We evaluated the long-term effects of SSI on health-care utilization and cost following orthopaedic surgery in an observational cohort study.METHODS: Patients in the Veterans Affairs health-care system who underwent an orthopaedic surgical procedure were included. The exposure of interest was an SSI within 90 days after the index procedure. The primary outcome was health-care utilization in the 2 years after discharge. Data for inpatient admission, inpatient days, outpatient visits, emergency room visits, total costs, and subsequent surgeries were also obtained. After adjusting for factors affecting SSI, we examined differences in each health-care utilization outcome by postoperative SSI occurrence and across time with use of differences-in-differences analysis. Cost differences were modeled with use of a gamma distribution with a log link.RESULTS: A total of 96,983 patients were included, of whom 4,056 (4.2%) had an SSI within 90 days of surgery. After adjusting for factors known to impact SSI and preoperative health-care utilization, SSI was associated with a greater risk of outpatient visits (relative risk [RR], 1.29; 95% confidence interval [CI], 1.26 to 1.32), emergency room visits (RR, 1.18; 95% CI, 1.15 to 1.21), and inpatient admission (RR, 1.35; 95% CI, 1.32 to 1.38) at 2 years postoperatively. The average cost among patients with an SSI was $148,824 ± $268,358 compared with $42,125 ± $124,914 among those without an SSI (p < 0.001). In the adjusted analysis, costs for patients with an SSI were 64% greater at 2 years compared with those without an SSI (RR, 1.64; 95% CI, 1.57 to 1.70). Overall, of all subsequent surgeries conducted within the 2-year postoperative period, 37% occurred within the first 90 days.CONCLUSIONS: The reported effects of a postoperative SSI on health-care utilization and cost are sustained at 2 years post-surgery-a long-term impact that is not recognized in quality-measurement models. Efforts, including preoperative care pathways and optimization, and policies, including reimbursement models and risk-adjustment, should be made to reduce SSI and to account for these long-term effects.LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.21.01278

  View details for PubMedID 35856929

• The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips JOURNAL OF HAND AND MICROSURGERY Shapiro, L. M., Chang, J., Fox, P. M., Kozin, S., Chung, K. C., Dyer, G. M., Fufa, D., Leversedge, F., Katarincic, J., Kamal, R. 2022

  View details for DOI 10.1055/s-0042-1749465

  View details for Web of Science ID 000822614800002

• Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study JOURNAL OF HAND AND MICROSURGERY Shapiro, L. M., Xiao, M., Zhuang, T., Ruch, D. S., Richard, M. J., Kamal, R. N. 2022

  View details for DOI 10.1055/s-0042-1749460

  View details for Web of Science ID 000822614800001

• Quality Measures for Pediatric Orthopaedic Surgery: A Systematic Review. Journal of pediatric orthopedics Montgomery, B. K., Welch, J. M., Shapiro, L. M., Shea, K. G., Kamal, R. N. 2022; 42 (6): e682-e687

  Abstract

  BACKGROUND: Quality measures provide a way to assess health care delivery and to identify areas for improvement that can inform patient care delivery. When operationalized by a hospital or a payer, quality measures can also be tied to physician or hospital reimbursement. Prior work on quality measures in orthopaedic surgery have identified substantial gaps in measurement portfolios and have highlighted areas for future measure development. This study aims to identify the portfolio of quality measures in pediatric orthopaedic surgery.METHODS: We used methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and reviewed PubMed/ MEDLINE and EMBASE, the American Academy of Orthopaedic Surgery (AAOS), National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ), for quality measures and candidate quality measures. Quality measure and candidate quality measures were categorized as structure, process, or outcome. Measures were also classified into 1 of the 6 National Quality Strategy priorities (safety, effective, patient centered, timely, efficient, and equitable).RESULTS: A review of PubMed/EMBASE returned 1640 potential quality measures and articles. A review of AAOS, NQF, and AHRQ databases found 80 potential quality measures. After screening we found a total of 18 quality measures and candidate quality measures specifically for pediatric orthopaedic surgery. Quality measures addressed conditions such as supracondylar humerus fractures, developmental dysplasia of the hip, and osteochondritis dissecans. There were 10 process measures, 8 outcome measure, and 0 structure measures. When we categorized by National Quality Strategy priorities and found 50% (9/18) were effective clinical care, 44% (8/18) were person and care-giver centered experience and outcomes, 6% (1/18) were efficient use of resources.CONCLUSIONS: There are few quality measures and candidate quality measures to assess pediatric orthopaedic surgery. Of the quality measure available, process measures are relatively over-represented. Pediatric orthopaedic surgeons can lead the development of outcome (eg, patient-reported outcomes after surgery) and structure measures (eg, subspecialty training certification) to assess quality of care in pediatric orthopaedic surgery.LEVEL OF EVIDENCE: Level II-systematic review.

  View details for DOI 10.1097/BPO.0000000000002126

  View details for PubMedID 35667057

• Health Literacy and Patient Participation in Shared Decision-Making in Orthopedic Surgery ORTHOPEDICS Mertz, K., Eppler, S., Shah, R., Yao, J., Steffner, R., Safran, M., Hu, S., Chou, L., Amanatullah, D. F., Kamal, R. N. 2022; 45 (4): 227-232

  Abstract

  The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score <6). Forty-eight percent of patients preferred to share decision-making with their physician equally (CPS score=3), whereas 38% preferred to have a more active role in decision-making (CPS score≤2). There was no statistically significant correlation between health literacy and patient preference for involvement in decision-making (r=0.130; P=.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [Orthopedics. 2022;45(4):227-232.].

  View details for DOI 10.3928/01477447-20220401-04

  View details for Web of Science ID 000831125900015

  View details for PubMedID 35394383

• Site of service of irrigation and debridement of open finger and hand fractures: a retrospective review of trends and outcomes CURRENT ORTHOPAEDIC PRACTICE Wadhwa, H., Zhuang, T., Shapiro, L. M., Welch, J. M., Richard, M. J., Kamal, R. N. 2022; 33 (4): 358-362

  View details for DOI 10.1097/BCO.0000000000001123

  View details for Web of Science ID 000816578100009

• Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis CURRENT ORTHOPAEDIC PRACTICE Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Maloney, W. J., Kamal, R. N. 2022; 33 (4): 338-346

  View details for Web of Science ID 000816578100006

• Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving? World journal of surgery Leversedge, C., Castro, S., Appiani, L. M., Kamal, R., Shapiro, L. 2022

  Abstract

  BACKGROUND: The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.METHODS: We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.RESULTS: The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4months (range: 15days-7years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3months while eight studies reported follow-up at or after 9months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.CONCLUSIONS: There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

  View details for DOI 10.1007/s00268-022-06630-w

  View details for PubMedID 35764890

• A Tool to Estimate Risk of 30-day Mortality and Complications After Hip Fracture Surgery: Accurate Enough for Some but Not All Purposes? A Study From the ACS-NSQIP Database. Clinical orthopaedics and related research Harris, A. H., Trickey, A. W., Eddington, H. S., Seib, C. D., Kamal, R. N., Kuo, A. C., Ding, Q., Giori, N. J. 2022

  Abstract

  Surgical repair of hip fracture carries substantial short-term risks of mortality and complications. The risk-reward calculus for most patients with hip fractures favors surgical repair. However, some patients have low prefracture functioning, frailty, and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult. The importance of high-quality informed consent and shared decision-making for frail patients with hip fracture has recently been demonstrated. A tool to accurately estimate patient-specific risks of surgery could improve these processes.With this study, we sought (1) to develop, validate, and estimate the overall accuracy (C-index) of risk prediction models for 30-day mortality and complications after hip fracture surgery; (2) to evaluate the accuracy (sensitivity, specificity, and false discovery rates) of risk prediction thresholds for identifying very high-risk patients; and (3) to implement the models in an accessible web calculator.In this comparative study, preoperative demographics, comorbidities, and preoperatively known operative variables were extracted for all 82,168 patients aged 18 years and older undergoing surgery for hip fracture in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2011 and 2017. Eighty-two percent (66,994 of 82,168) of patients were at least 70 years old, 21% (17,007 of 82,168) were at least 90 years old, 70% (57,260 of 82,168) were female, and 79% (65,301 of 82,168) were White. A total of 5% (4260 of 82,168) of patients died within 30 days of surgery, and 8% (6786 of 82,168) experienced a major complication. The ACS-NSQIP database was chosen for its clinically abstracted and reliable data from more than 600 hospitals on important surgical outcomes, as well as rich characterization of preoperative demographic and clinical predictors for demographically diverse patients. Using all the preoperative variables in the ACS-NSQIP dataset, least absolute shrinkage and selection operator (LASSO) logistic regression, a type of machine learning that selects variables to optimize accuracy and parsimony, was used to develop and validate models to predict two primary outcomes: 30-day postoperative mortality and any 30-day major complications. Major complications were defined by the occurrence of ACS-NSQIP complications including: on a ventilator longer than 48 hours, intraoperative or postoperative unplanned intubation, septic shock, deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, sepsis, intraoperative or postoperative myocardial infarction, intraoperative or postoperative cardiac arrest requiring cardiopulmonary resuscitation, acute renal failure needing dialysis, pulmonary embolism, stroke/cerebral vascular accident, and return to the operating room. Secondary outcomes were six clusters of complications recently developed and increasingly used for the development of surgical risk models, namely: (1) pulmonary complications, (2) infectious complications, (3) cardiac events, (4) renal complications, (5) venous thromboembolic events, and (6) neurological events. Tenfold cross-validation was used to assess overall model accuracy with C-indexes, a measure of how well models discriminate patients who experience an outcome from those who do not. Using the models, the predicted risk of outcomes for each patient were used to estimate the accuracy (sensitivity, specificity, and false discovery rates) of a wide range of predicted risk thresholds. We then implemented the prediction models into a web-accessible risk calculator.The 30-day mortality and major complication models had good to fair discrimination (C-indexes of 0.76 and 0.64, respectively) and good calibration throughout the range of predicted risk. Thresholds of predicted risk to identify patients at very high risk of 30-day mortality had high specificity but also high false discovery rates. For example, a 30-day mortality predicted risk threshold of 15% resulted in 97% specificity, meaning 97% of patients who lived longer than 30 days were below that risk threshold. However, this threshold had a false discovery rate of 78%, meaning 78% of patients above that threshold survived longer than 30 days and might have benefitted from surgery. The tool is available here: https://s-spire-clintools.shinyapps.io/hip_deploy/.The models of mortality and complications we developed may be accurate enough for some uses, especially personalizing informed consent and shared decision-making with patient-specific risk estimates. However, the high false discovery rate suggests the models should not be used to restrict access to surgery for high-risk patients. Deciding which measures of accuracy to prioritize and what is "accurate enough" depends on the clinical question and use of the predictions. Discrimination and calibration are commonly used measures of overall model accuracy but may be poorly suited to certain clinical questions and applications. Clinically, overall accuracy may not be as important as knowing how accurate and useful specific values of predicted risk are for specific purposes.Level of Evidence Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000002294

  View details for PubMedID 35901441

• Do Patients Want to be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study. The Journal of hand surgery Roe, A. K., Eppler, S. L., Kakar, S., Akelman, E., Got, C. J., Blazar, P. E., Ruch, D. S., Richard, M. J., Yao, J., Kamal, R. N. 2022

  Abstract

  PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome.METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated.RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared.CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions.CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

  View details for DOI 10.1016/j.jhsa.2022.03.025

  View details for PubMedID 35672175

• Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis. Current orthopaedic practice Zhuang, T., Shapiro, L. M., Amanatullah, D. F., Maloney, W. J., Kamal, R. N. 2022; 33 (4): 338-346

  Abstract

  Poorly controlled diabetes mellitus (DM) increases the risk for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). While institutional protocols include hemoglobin A1c (HbA1c) screening in TJA patients, the costs and benefits of routine preoperative screening have not been described.The authors created a decision tree model to evaluate short-term costs and risk reduction for PJIs with routine screening of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. Probabilities and costs were obtained from published sources. They calculated net costs and absolute risk reduction in PJI for routine screening versus no screening. The authors also performed sensitivity analyses of model inputs including probabilistic sensitivity analyses (PSAs) consisting of 10,000 Monte Carlo simulations.In patients with DM, routine screening before THA resulted in net cost savings of $81 per patient with 286 patients needing to be screened to prevent 1 PJI, while screening before TKA incurred net additional costs of $25,810 per PJI prevented. Routine screening in patients with DM undergoing THA or TKA was cost-saving across 75.5% or 21.8% of PSA simulations, respectively. In patients with no history of DM, routine screening before THA or TKA incurred net additional costs of $24,583 or $87,873 per PJI prevented, respectively.Routine HbA1c screening in patients with DM prior to THA with referral of patients with elevated HbA1c for glycemic optimization may prevent PJI and reduce healthcare costs. In contrast, routine screening in patients with DM prior to TKA or in patients with no history of DM is not cost-saving.Economic Level IV.

  View details for DOI 10.1097/bco.0000000000001131

  View details for PubMedID 36340586

  View details for PubMedCentralID PMC9632610

• Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clinical orthopaedics and related research Welch, J. M., Zhuang, T., Shapiro, L. M., Harris, A. H., Baker, L. C., Kamal, R. N. 2022

  Abstract

  Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000002255

  View details for PubMedID 35608508

• Site of service of irrigation and debridement of open finger and hand fractures: a retrospective review of trends and outcomes. Current orthopaedic practice Wadhwa, H., Zhuang, T., Shapiro, L. M., Welch, J. M., Richard, M. J., Kamal, R. N. 2022; 33 (4): 358-362

  Abstract

  Irrigation and debridement (I&D) of open finger and hand fractures can be performed in the emergency department as opposed to the operating room (OR), though reports of postoperative infection rates vary greatly. The authors hypothesized that I&D of open finger and hand fractures in the OR would decrease over time. They also describe rates of postoperative infection, reoperation, readmission, and costs.A large nationwide administrative claims dataset was retrospectively reviewed to identify patients who underwent I&D after open finger and hand fractures from 2007 to 2016. The incidence of I&D procedures performed outside the OR was reported and trends over the study period were assessed.The proportion of open finger and hand fractures that underwent I&D outside the OR did not change significantly over time. Rates of postoperative surgical site infection, readmission, and reoperation were higher in the OR cohort at 90 days after the index stay. The OR cohort had greater total costs and out-of-pocket costs for the index stay. At 90 days, the OR cohort had greater total cost, but out-of-pocket costs were similar.Site of service for treatment of open finger and hand fractures has not significantly changed from 2007 to 2016. Given that total costs are significantly greater among patients undergoing I&D in the OR, prospective trials are needed to assess the safety of treating open finger and hand fractures outside of the OR to optimize management of these injuries.III.

  View details for DOI 10.1097/bco.0000000000001123

  View details for PubMedID 36188628

  View details for PubMedCentralID PMC9524536

• Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care ORTHOPEDICS MURASKO, M. J., V. IVANOV, D. D., ROE, A. K., KAMAL, R. N., AMANATULLAH, D. F. 2022; 45 (3): E127-+

  Abstract

  Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

  View details for DOI 10.3928/01477447-20220217-06

  View details for Web of Science ID 000800016300002

  View details for PubMedID 35201936

• How do orthopaedic surgery residency program websites feature diversity? An analysis of 187 orthopaedic surgery programs in the United States. Current orthopaedic practice Cohen, S. A., Xiao, M., Zhuang, T., Michaud, J., Wadhwa, H., Shapiro, L., Kamal, R. N. 2022; 33 (3): 258-263

  Abstract

  Background: The orthopaedic surgery residency program website represents a recruitment tool that can be used to demonstrate a program's commitment to diversity and inclusion to prospective applicants. The authors assessed how orthopaedic surgery residency programs demonstrated diversity and inclusion on their program websites and whether this varied based on National Institutes of Health (NIH) funding, top-40 medical school affiliation, university affiliation, program size, or geographic region.Methods: The authors evaluated 187 orthopaedic surgery residency program websites for the presence of 12 elements that represented program commitment to diversity and inclusion values, based on prior work and ACGME recommendations. Mann-Whitney U and Kruskal-Wallis tests were used to assess whether NIH funding and other program characteristics were associated with commitment to diversity and inclusion on affiliated residency websites.Results: Orthopaedic surgery residency websites included a mean of 4.9 ± 2.1 diversity and inclusion elements, with 21% (40/187) featuring a majority (7+) of elements. Top 40 NIH funded programs (5.4 ± 2.0) did not have significantly higher website diversity scores when compared with nontop-40 programs (4.8 ± 2.1) (P = 0.250). University-based or affiliated programs (5.2 ± 2.0) had higher diversity scores when compared with community-based programs (3.6 ± 2.2) (P = 0.003).Conclusions: Most orthopaedic surgery residency websites contained fewer than half of the diversity and inclusion elements studied, suggesting opportunities for further commitment to diversity and inclusion. Inclusion of diversity initiatives on program websites may attract more diverse applicants and help address gender and racial or ethnic disparities in orthopaedic surgery.Level of Evidence: Level V.

  View details for DOI 10.1097/bco.0000000000001101

  View details for PubMedID 35685001

• Practical Application of the 2020 Distal Radius Fracture AAOS/ASSH Clinical Practice Guideline: A Clinical Case. The Journal of the American Academy of Orthopaedic Surgeons Kamal, R. N., Shapiro, L. M. 2022

  Abstract

  The Clinical Practice Guideline Management of Distal Radius Fractures released by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand is a summary of the available evidence designed to guide surgeons and other qualified physicians in the management of distal radius fractures. According to this guideline, age of 65 is used as a proxy for functional activity and can serve as a threshold under which patients are likely to benefit from surgical fixation and over which patients are less likely to benefit from surgical fixation when compared with nonsurgical treatment. Supervised therapy and arthroscopic assistance should be used sparingly and on a case-by-case basis. Routine radiographs should also be used on a case-by-case basis. As strong evidence suggests no difference observed in clinical or radiographic outcomes by fixation technique used after 3 months, fixation technique should be driven by fracture pattern. These guidelines serve to guide physicians in the care of patients with distal radius fractures.

  View details for DOI 10.5435/JAAOS-D-21-01194

  View details for PubMedID 35383613

• Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable? Clinical orthopaedics and related research Harris, A. H., Ding, Q., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Yoshida, R., Lashgari, D., Nuckols, T. K., Kamal, R. N. 2022

  Abstract

  BACKGROUND: The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information.QUESTIONS/PURPOSES: (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)?METHODS: This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied.To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size.RESULTS: We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60.CONCLUSION: The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes.CLINICAL RELEVANCE: As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.

  View details for DOI 10.1097/CORR.0000000000002175

  View details for PubMedID 35274625

• Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries. Hand (New York, N.Y.) Welch, J. M., Kamal, R. N., Chatterjee, M., Shapiro, L. M. 1800: 15589447211072200

  Abstract

  BACKGROUND: Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs.METHODS: Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis.RESULTS: Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework.CONCLUSIONS: This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.

  View details for DOI 10.1177/15589447211072200

  View details for PubMedID 35048744

• Implementation of Electronic Health Records During Global Outreach: A Necessary Next Step in Measuring and Improving Quality of Care. The Journal of hand surgery Shapiro, L. M., Kamal, R. N. 2021

  Abstract

  There has been a marked improvement in health outcomes in low- and middle-income countries (LMICs) throughout the past several decades. Although access to care has increased, evidence demonstrates that over 8 million lives could be saved annually with high-quality health systems. Traumatic injuries that are often treatable by surgical services are a leading cause of global mortality. As such, increased efforts toward improving quality of care in addition to access are needed for surgical services in LMICs. Electronic health records have become standard in high-income countries, given their demonstrated ability to improve clinical care, prevent complications, and inform quality improvement. Electronic health records are not frequently used in LMICs and represent an opportunity to address the quality gap in these health systems. This review highlights the benefits of electronic health records in high-income countries, their potential benefits in LMICs, their current role in supporting surgical outreach, and their implementation on outreach trips to measure and improve quality of care.

  View details for DOI 10.1016/j.jhsa.2021.09.016

  View details for PubMedID 34756514

• The Intercalated Segment: Does the Triquetrum Move in Synchrony With the Lunate? The Journal of hand surgery Mack, Z. E., Kamal, R. N., Best, G. M., Wolfe, S. W., Pichora, D. R., Rainbow, M. J. 2021

  Abstract

  PURPOSE: To quantify the relative motion between the lunate and triquetrum during functional wrist movements and to examine the impact of wrist laxity on triquetral motion.METHODS: A digital database of wrist bone anatomy and carpal kinematics for 10 healthy volunteers in 10 different positions was used to study triquetral kinematics. The orientation of radiotriquetral (RT) and radiolunate rotation axes was compared during a variety of functional wrist movements, including radioulnar deviation (RUD) and flexion-extension (FE), and during a hammering task. The motion of the triquetrum relative to the radius during wrist RUD was compared with passive FE range of motion measurements (used as a surrogate measure for wrist laxity).RESULTS: The difference in the orientation of the radiolunate and RT rotation axes was less than 20° during most of the motions studied, except for radial deviation and for the first stage of the hammering task. During wrist RUD, the orientation of the RT rotation axis varied as a function of passive FE wrist range of motion.CONCLUSIONS: The suggestion that the lunate and triquetrum move together as an intercalated segment may be an oversimplification. We observed synchronous movement during some motions, but as the wrist entered RUD, the lunate and triquetrum no longer moved synchronously. These findings challenge the assumptions behind models describing the mechanical function of the carpals.CLINICAL RELEVANCE: Individual-specific differences in the amount of relative motion between the triquetrum and lunate may contribute to the variability in outcomes following lunotriquetral arthrodesis. Variation in triquetral motion patterns may also have an impact on the ability of the triquetrum to extend the lunate, affecting the development of carpal instability.

  View details for DOI 10.1016/j.jhsa.2021.08.014

  View details for PubMedID 34627631

• A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Lai, C. H., Shapiro, L. M., Amanatullah, D. F., Chou, L. B., Gardner, M. J., Hu, S. S., Safran, M. R., Kamal, R. N. 2021

  Abstract

  PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians.METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted.RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and(3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care.CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

  View details for DOI 10.1007/s11136-021-02972-5

  View details for PubMedID 34510335

• How Is Scaphoid Malunion Defined: A Systematic Review. Hand (New York, N.Y.) Xiao, M., Welch, J. M., Cohen, S. A., Kamal, R. N., Shapiro, L. M. 2021: 15589447211038678

  Abstract

  BACKGROUND: Abnormal scaphoid alignment after fracture is used as an indication for fixation. Acceptable alignment after reduction and fixation of scaphoid fractures is not well defined. We systematically reviewed the literature to identify how scaphoid malunion is currently defined and by what parameters.METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were searched for studies published in the English language that reported on outcomes after scaphoid malunion and included measurements to define malunions. Radiographic scaphoid measurement parameters were collected. Clinical outcome measures recorded included grip strength, wrist range of motion, and patient-reported outcome measures. Study quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Descriptive summaries of the studies are presented.RESULTS: The initial search yielded 1600 articles. Ten articles (161 participants, 93% males, mean age = 28.3 + 6.3 years, mean MINORS score = 10.2 + 1.6) were included and analyzed. Scaphoid malunion was defined if the lateral intrascaphoid angle (LISA) was >45° (3 articles), LISA >35° (1 article), and height to length ratio >0.6 (3 articles). Four out of 5 studies found no significant associations between patient outcomes and degree of scaphoid malunion measured on imaging.CONCLUSIONS: There is a lack of consensus for defining scaphoid malunion on imaging and absence of correlation between findings on imaging and patient outcomes. Future studies defining scaphoid malunion should be appropriately powered, incorporate measures of intrarater and interrater reliabilities for all reported imaging measurements, and utilize validated patient-reported outcome measures to reflect that malunion is associated with inferior outcomes meaningful to patients.

  View details for DOI 10.1177/15589447211038678

  View details for PubMedID 34486427

• Distal Radius Fracture Clinical Practice Guidelines-Updates and Clinical Implications. The Journal of hand surgery Shapiro, L. M., Kamal, R. N. 2021

  Abstract

  The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand released updated Clinical Practice Guidelines in 2020 on the evaluation and treatment of acute distal radius fractures. Following a rigorous methodology designed and implemented through the AAOS, 7 guidelines based upon the best available evidence were released to assist surgeons and physicians managing distal radius fractures. These guidelines can serve as a reference for surgeons when managing patients with distal radius fractures. We review the evidence behind each guideline and highlight the practical implications of each guideline on care.

  View details for DOI 10.1016/j.jhsa.2021.07.014

  View details for PubMedID 34384642

• Outcome Metrics in the Treatment of Distal Radius Fractures in Patients Aged Above 50 Years: A Systematic Review. Hand (New York, N.Y.) Fogel, N., Mertz, K., Shapiro, L. M., Roe, A., Denduluri, S., Kamal, R. N. 2021: 15589447211028919

  Abstract

  BACKGROUND: The inclusion of patient-reported outcome measures (PROMs) serves to better quantify aspects of patient outcomes missed with objective measures, including radiographic indices and physical examination findings. We hypothesize that PROMs are inconsistently and heterogeneously captured in the treatment of distal radius fractures.METHODS: We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines of all level I and II randomized controlled trials (RCTs) of distal radius fracture treatment of any modality for those older than 50 years of age from January 2008 to January 2018. A total of 23 studies were included in the final analysis. The metrics used by each study to assess outcomes were collected, compared, and described.RESULTS: Physical examination findings and radiographic measures were reported in 70% and 74% of studies, respectively. Patient-reported outcomes measures were used to assess outcomes in 74% of studies. Only the Disabilities of the Arm, Shoulder, and Hand was used in greater than half of the studies (57%). Pain scores were assessed in 39% of studies and complications in only 26%.CONCLUSIONS: There is substantial heterogeneity and lack of standardization in the collection of both objective outcome measures and PROMs in level I and II RCTs for the treatment of distal radius fractures. The ability to compare between studies or aggregate data among studies is therefore limited. Radiographic and physical examination findings remain frequently reported despite known limitations of these metrics. The routine collection of PROMs after the treatment of distal radius fractures can ensure care is directed toward improving what is most important to patients.

  View details for DOI 10.1177/15589447211028919

  View details for PubMedID 34286628

• Short Message Service-Based Collection of Patient-Reported Outcome Measures on Hand Surgery Global Outreach Trips: A Pilot Feasibility Study. The Journal of hand surgery Shapiro, L. M., Dinh, M. P., Tran, L., Fox, P. M., Richard, M. J., Kamal, R. N. 2021

  Abstract

  PURPOSE: As the burden of surgical care and the associated outreach trips to low- and middle-income countries increases, it is important to collect postoperative data to assess and improve the quality, safety, and efficacy of the care provided. In this pilot study, we aimed to evaluate the feasibility of short message service (SMS)-based mobile phone follow up to obtain patient-reported outcome measures after hand surgery during a surgical outreach trip to Vietnam.METHODS: Patients undergoing surgery during a week-long outreach trip to Hospital 175 in Ho Chi Minh City, Vietnam, who owned a mobile phone, were included in this study. Eight eligible patients elected to participate and were sent an SMS-based, Health Insurance Portability and Accountability Act-compliant text message with a link to a contextualized shortened Disabilities of the Arm, Shoulder and Hand questionnaire at 1 day, 1 week, 2 weeks, 4 weeks, and 12 weeks after the surgery. The patient characteristics and instrument completion rates were reported.RESULTS: The 8 patients had a mean age of 45.4 years and lived at a mean distance of 72.7 km from the hospital. Seven (87.5%), 7 (87.5%), 8 (100%), 6 (75%), and 8 (100%) patients completed the follow-up questionnaires at 1 day, 1 week, 2 weeks, 4 weeks, and 12 weeks after the surgery, respectively.CONCLUSIONS: This pilot study demonstrates that the collection of patient-reported outcome measures after hand surgery outreach trips to low- and middle-income countries via SMS-based messaging is feasible for up to 12 weeks after the surgery.CLINICAL RELEVANCE: Short message service-based messaging can be used to obtain postoperative outcome measures for up to 12 weeks after surgical outreach trips to low- and middle-income countries. This technology can be scaled and contextualized based on location to ensure that patient care during outreach trips is safe and effective.

  View details for DOI 10.1016/j.jhsa.2021.05.001

  View details for PubMedID 34148790

• Google Trends Analysis Shows Increasing Public Interest in Platelet-Rich Plasma Injections for Hip and Knee Osteoarthritis. The Journal of arthroplasty Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Amanatullah, D. F., Kamal, R. N. 2021

  Abstract

  BACKGROUND: Osteoarthritis is a chronic musculoskeletal condition that frequently affects the hip and knee joints. Given the burden associated with surgical intervention for hip and knee osteoarthritis, patients continue to search for potential nonoperative treatments. One biologic therapy with mixed clinical and basic science evidence for treating osteoarthritis is platelet-rich plasma injections into the affected joint. We used the Google Trends tool to provide a quantitative analysis of national interest in platelet-rich plasma injections for hip and knee osteoarthritis.METHODS: Google Trends parameters were selected to obtain search data from January 2009 to December 2019. Various combinations of "arthritis," "osteoarthritis," "PRP," "platelet-rich plasma," "knee," and "hip" were entered into the Google Trends tool and trend analyses were performed.RESULTS: Three linear models were generated to display search volume trends in the United States for platelet-rich plasma and osteoarthritis, hip osteoarthritis, and knee osteoarthritis, respectively. All models showed increased Google queries as time progressed (P < .001), with R2 ranging from 0.837 to 0.940. Seasonal, income-related, and geographic variations in public interest in platelet-rich plasma for osteoarthritis were noted.CONCLUSION: Our results demonstrate a significant rise in Google queries related to platelet-rich plasma injections for osteoarthritis of the hip and knee since 2009. Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data. Trends in public interest may inform patient counseling, shared decision-making, and directions for future clinical research.

  View details for DOI 10.1016/j.arth.2021.05.040

  View details for PubMedID 34172346

• Perioperative Laboratory Markers as Risk Factors for Surgical Site Infection After Elective Hand Surgery. The Journal of hand surgery Zhuang, T., Shapiro, L. M., Fogel, N., Richard, M. J., Gardner, M. J., Kamal, R. N. 2021

  Abstract

  PURPOSE: The purpose of this study was to test the null hypothesis that there is no association between perioperative laboratory markers (serum albumin and hemoglobin A1c [HbA1c]) and incidence of surgical site infection (SSI) after soft tissue upper extremity surgery.METHODS: We analyzed patient-level data from a large, insurance-based database containing supplemental laboratory results. We identified patients undergoing soft tissue upper extremity surgery (defined as carpal tunnel release, trigger finger release, wrist ganglion excision, cubital tunnel release, Dupuytren partial fasciectomy, or first dorsal compartment release) with serum albumin or HbA1c measurements within 90 days of surgery. We stratified patients into cohorts based on serum albumin concentration (<3.5 g/dL) and HbA1c (≥7%) thresholds. The primary outcome was incidence of SSI within 30 days following surgery. We constructed multivariable logistic regression models to adjust for patient demographics and baseline comorbidities using the Elixhauser comorbidity index.RESULTS: Patients with hypoalbuminemia experienced an SSI incidence of 3.5% compared to 0.9% in patients with normal serum albumin. In multivariable analysis, the odds ratio of SSI with hypoalbuminemia was 3.32 (95% CI, 2.32-4.65). Patients with HbA1c ≥ 7% experienced an SSI incidence of 1.1% compared to 0.7% in patients with HbA1c < 7%. Multivariable analysis revealed odds ratios for SSI of 1.47 (95% CI, 1.02-2.11) in patients with HbA1c ≥ 7% compared to those with HbA1c < 7%.CONCLUSIONS: Hypoalbuminemia and elevated HbA1c (in patients with diabetes) are risk factors for SSI within 30 days following soft tissue upper extremity surgery. Preoperative measurement of these laboratory markers may be a useful tool for risk stratification and identification of high-risk patients for nutritional or glycemic optimization.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

  View details for DOI 10.1016/j.jhsa.2021.04.001

  View details for PubMedID 34016493

• Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA network open Mudumbai, S. C., Pershing, S., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M. T., Eisenberg, D., Finlay, A. K., Hagedorn, H., Harris, A. H. 2021; 4 (5): e217470

  Abstract

  Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P<.001) at the facility level and 0.06 (P<.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

  View details for DOI 10.1001/jamanetworkopen.2021.7470

  View details for PubMedID 33956131

• CORR Insights: Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options. Clinical orthopaedics and related research Kamal, R. N. 2021

  View details for DOI 10.1097/CORR.0000000000001791

  View details for PubMedID 33938513

• Barriers and Facilitators of Outcome Collection During Hand Surgery Outreach: A Quality Improvement Study. Hand (New York, N.Y.) Shapiro, L. M., Dinh, M. P., Fox, P. M., Richard, M. J., Eppler, S. L., Kamal, R. N. 2021: 15589447211003183

  Abstract

  BACKGROUND: Surgical outreach trips to low- and middle-income countries have been increasing. Outcome collection on these trips, however, has been inconsistent and often incomplete. We conducted a qualitative study of surgeons, administrators, and patients to identify the barriers and facilitators to outcome collection on hand surgery outreach trips to Hospital 175 in Ho Chi Minh City, Vietnam.METHODS: A purposive sample of surgeons, administrators, and patients from Hospital 175 were interviewed about their beliefs regarding outcome collection. We used a semi-structured interview guide based on the Theoretical Domains Framework to systematically explore barriers and facilitators. Interviews were recorded, transcribed, and analyzed using content analysis. Beliefs underlying similar responses were identified and aggregated to describe barriers and facilitators of outcome measurement.RESULTS: Twelve surgeons and administrative staff (3 visiting and 9 local) and 5 patients were interviewed before saturation was achieved. All stakeholders believed outcome collection on hand surgery outreach trips is important. Barriers identified were primarily related to environmental context and resources (eg, cost of returning) and memory, attention, and decision process (eg, difficulty in remembering patient follow-up intervals). The most commonly identified barriers address the distance patients live from the hospital/clinic, the resources required for them to return, and the lack of an organized system to assist in follow-up.CONCLUSIONS: Multiple barriers to outcome collection exist at Hospital 175 in Vietnam. Understanding these barriers informs context-specific implementation approaches to collect outcomes on hand surgery outreach trips, which may improve the safety and quality of care provided.

  View details for DOI 10.1177/15589447211003183

  View details for PubMedID 33789491

• Engaging Patients to Ask More Questions: What's the Best Way? A Pragmatic Randomized Controlled Trial. The Journal of hand surgery Roe, A. K., Eppler, S. L., Shapiro, L. M., Satteson, E. S., Yao, J., Kamal, R. N. 2021

  Abstract

  PURPOSE: Hand conditions are common, and often require a discussion of the tradeoffs of different treatment options. Our goal was to evaluate whether providing patients with a Question Prompt List (QPL) for common hand conditions improves their perceived involvement in care compared with providing patients with 3 generic questions.METHODS: We performed a prospective, single-center, pragmatic randomized controlled trial. We created a QPL pamphlet for patients with common hand conditions. New patients with common hand conditions were enrolled between April 2019 and July 2019 and were randomized into either the QPL group (with 35 hand-specific questions) or the AskShareKnow group (3 generic questions: [1] What are my options? [2] What are the possible benefits and harms of those options? [3] How likely are each of these benefit and harms to happen to me?). Both groups received the questions prior to meeting with their surgeon. We used the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient participation in decision-making, as our primary outcome. The maximum PICS score is 13, and a higher score indicates higher perceived involvement.RESULTS: One hundred twenty-six patients participated in the study, with 63 patients in the QPL group and 63 patients in the AskShareKnow group. The demographic characteristics were similar in the 2 groups. The mean AskShareKnow group PICS score was 8.3 ± 2.2 and the mean QPL PICS score was 7.5 ± 2.8, which was not deemed clinically significant.CONCLUSIONS: The QPLs do not increase perceived involvement in care in patients with hand conditions compared with providing patients with 3 generic questions.CLINICAL RELEVANCE: Various approaches have been evaluated to help improve patient involvement in their care. In hand surgery, 3 generic questions were no different than a lengthy QPL with respect to patient involvement in their care.

  View details for DOI 10.1016/j.jhsa.2021.02.001

  View details for PubMedID 33775464

• Using Google Trends Data to Track Healthcare Use for Hand Osteoarthritis CUREUS Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Shapiro, L., Kamal, R. N. 2021; 13 (3)

  View details for DOI 10.7759/cureus.13786

  View details for Web of Science ID 000627816200013

• Using Google Trends Data to Track Healthcare Use for Hand Osteoarthritis. Cureus Cohen, S. A., Zhuang, T., Xiao, M., Michaud, J. B., Shapiro, L., Kamal, R. N. 2021; 13 (3): e13786

  Abstract

  Background Google Trends (GT) is a free tool that provides analysis of search traffic for specified terms entered into the Google search engine. In this study, we evaluate the association between public interest in hand osteoarthritis (OA) as determined by GT search volumes and healthcare usage related to hand OA. Methodology We compiled GT data from 2010 to 2017 for the following group of hand OA-related search terms: "hand osteoarthritis," "hand arthritis," "hand swelling," "hand stiffness," and "chronic hand pain." Claims associated with hand OA codes were obtained from an administrative database (14.8 million patients) using International Classification of Diseases codes from 2010 to 2017. We performed trend analysis using univariate linear regression of GT data and hand OA claims. A month-by-month analysis of variation from yearly GT means was conducted for hand OA-related search terms. Results There was increased public interest in hand OA-related search terms from January 2010 to December 2017. Univariate linear regression of GT data for hand OA-related search terms compared with hand OA claims demonstrated a significant positive correlation (p < 0.001, r = 0.707). Peak public interest in hand OA-related search terms was observed in July, May, and June. Conclusions This study demonstrates the ability of GT to track healthcare use related to hand OA. Our data also add to the evidence for monthly variations in public interest related to hand OA. Clinics and surgery centers can employ GT data to anticipate resource utilization by hand OA patients.

  View details for DOI 10.7759/cureus.13786

  View details for PubMedID 33842160

  View details for PubMedCentralID PMC8025802

• A Qualitative Study of Patient Themes for the Quality of the Total Joint Arthroplasty Experience ORTHOPEDICS Amanatullah, D. F., Eppler, S. L., Shah, R. F., Mertz, K., Roe, A. K., Murasko, M., Kamal, R. N. 2021; 44 (2): 117–22

  View details for DOI 10.3928/01477447-20210217-01

  View details for Web of Science ID 000634508300034

• Understanding the Patient Experience: Analysis of 2-Word Assessment and Its Relationship to Likelihood to Recommend in Outpatient Hand Surgery. Hand (New York, N.Y.) Shapiro, L. M., Thomas, K. A., Eppler, S. L., Behal, R. n., Yao, J. n., Kamal, R. N. 2021: 1558944720988078

  Abstract

  Actionable feedback from patients after a clinic visit can help inform ways to better deliver patient-centered care. A 2-word assessment may serve as a proxy for lengthy post-visit questionnaires. We tested the use of a 2-word assessment in an outpatient hand clinic.New patients were asked to provide a 2-word assessment of the following: (1) their physician; (2) their overall experience; and (3) recommendations for improvement and their likelihood to recommend (LTR) after their clinic visit. Sentiment analysis was used to categorize results into positive, neutral, or negative sentiment. Recommendations for improvement were classified into physician issue, system issue, or neither. We evaluated the relationship between LTR status, sentiment, actionable improvement opportunities, and classification (physician issue, system issue, or neither). Recommendations for improvement were classified into themes based on prior literature.Sixty-seven (97.1%) patients noted positive sentiment toward their physician; 67 (97.1%) noted positive sentiment toward their overall experience. About 31% of improvement recommendations were system-based, 5.9% were physician-based, and 62.7% were neither. Patients not LTR were more likely to leave actionable opportunities for improvement than those LTR (P = .01). Recommendations for improvement were classified into predetermined themes relating to: (1) physician interaction; (2) check-in process; (3) facilities; (4) unnecessary visit; and (5) appointment delays.Patients not likely to recommend provided actionable opportunities for improvement using a simple 2-word assessment. Implementation of a 2-word assessment in a hand clinic can be used to obtain actionable, real-time patient feedback that can inform operational change and improve the patient experience.

  View details for DOI 10.1177/1558944720988078

  View details for PubMedID 33478269

• The Impact of Certificate of Need Status on the Utilization and Reimbursement of Open and Endoscopic Carpal Tunnel Release. Journal of surgical orthopaedic advances Denduluri, S. K., Roe, A., Bala, A., Fogel, N., Ziino, C., Kamal, R. N. 2021; 30 (2): 90-92

  Abstract

  A certificate of need (CON) permits a healthcare organization to build new facilities only if significant medical needs exist. Many states have implemented CON programs to prevent procedure overutilization and price inflation. We hypothesized that there are no differences in reimbursement or utilization for open and endoscopic carpal tunnel release (CTR) when comparing states with and without CON programs. We queried a private-payer database to identify open and endoscopic CTRs performed between 2007 and 2015. In total, 82,689 CTRs were identified: 70,160 open, 12,529 endoscopic. Reimbursement increased for open procedures (compound annual growth rate [CAGR] 1.0% CON, 1.4% non-CON) but only marginally increased or decreased in the endoscopic group (CAGR -0.8% CON, 0.2% non-CON). Utilization increased across all settings, and was highest in the endoscopic CON group (CAGR 17.9%). Least growth was seen in the open non-CON group (CAGR 10.0%). Overall, CON programs may not actually decrease CTR spending or utilization. (Journal of Surgical Orthopaedic Advances 30(2):090-092, 2021).

  View details for PubMedID 34181524

• Is Uncontrolled Diabetes Mellitus Associated with Incidence of Complications After Posterior Instrumented Lumbar Fusion? A National Claims Database Analysis. Clinical orthopaedics and related research Zhuang, T. n., Feng, A. Y., Shapiro, L. M., Hu, S. S., Gardner, M. n., Kamal, R. N. 2021

  Abstract

  Previous research has shown that diabetes mellitus (DM) is associated with postoperative complications, including surgical site infections (SSIs). However, evidence for the association between diabetes control and postoperative complications in patients with DM is mixed. Prior studies relied on a single metric for defining uncontrolled DM, which does not account for glycemic variability, and it is unknown whether a more comprehensive assessment of diabetes control is associated with postoperative complications.(1) Is there a difference in the incidence of SSI after lumbar spine fusion in patients with uncontrolled DM, defined with a comprehensive assessment of glycemic control, compared with patients with controlled DM? (2) Is there a difference in the incidence of other select postoperative complications after lumbar spine fusion in patients with uncontrolled DM compared with patients with controlled DM? (3) Is there a difference in total reimbursements between these groups?We used the PearlDiver Patient Records Database, a national administrative claims database that provides access to the full continuum of perioperative care. We included 46,490 patients with DM undergoing posterior lumbar fusion with instrumentation. Patients were required to be continuously enrolled in the database for at least 1 year before and 90 days after the index procedure. Patients were divided into uncontrolled and controlled DM cohorts, as defined by ICD-9 diagnostic codes. These are based on a comprehensive assessment of glycemic control, including consideration of patient self-monitoring of blood glucose levels, hemoglobin A1c, and the presence/severity of diabetes-related comorbidities. The cohorts differed only by age, insurance type, and Elixhauser comorbidity score. The primary outcome was the incidence of SSI, divided into superficial and deep, within 90 days postoperatively. Secondary complications included the incidence of cerebrovascular events, acute kidney injury, pulmonary embolism, pneumonia, urinary tract infection, blood transfusion, and total reimbursements. These are the sum of reimbursements occurring within 90 days of surgery, which capture the total professional and facility cost burden to the health payer (such as the insurer). We constructed multivariable logistic regression models to adjust for the effects of age, insurance type, and comorbidities.After adjusting for potentially confounding variables including age, insurance type, and comorbidities, we found that patients with uncontrolled DM had an odds ratio for deep SSI of 1.52 (95% confidence interval 1.16 to 1.95; p = 0.002). Similarly, patients with uncontrolled DM had adjusted odds ratios of 1.25 (95% CI 1.01 to 1.53; p = 0.03) for cerebrovascular events, 1.36 (95% CI 1.18 to 1.57; p < 0.001) for acute kidney injury, 1.55 (95% CI 1.16 to 2.04; p = 0.002) for pulmonary embolism, 1.30 (95% CI 1.08 to 1.54; p = 0.004) for pneumonia, 1.33 (95% CI 1.19 to 1.49; p < 0.001) for urinary tract infection, and 1.27 (95% CI 1.04 to 1.53; p = 0.02) for perioperative transfusion. Patients with uncontrolled DM had higher median 90-day total reimbursements than patients with controlled DM: USD 27,915 (interquartile range 5472 to 63,400) versus USD 10,263 (IQR 4101 to 49,748; p < 0.001).Our findings encourage surgeons to take a full diabetic history beyond the HbA1c value, including any self-monitoring of glucose measurements, time in acceptable range for continuous glucose monitors, and/or consideration of the presence/severity of diabetes-related complications before lumbar spine fusion, as HbA1c does not fully capture glycemic control or variability. We emphasize that uncontrolled DM is a clinical, rather than laboratory, diagnosis. Comprehensive diabetes histories should be incorporated into existing preoperative diabetes care pathways and elective surgery could be deferred to improve glycemic control. Future development of an index measure incorporating multidimensional measures of diabetes control (such as continuous or self-glucose monitoring, diabetes-related comorbidities) is warranted.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000001823

  View details for PubMedID 34014844

• Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions. JBJS reviews Lemos, J. L., Welch, J. M., Xiao, M., Shapiro, L. M., Adeli, E., Kamal, R. N. 1800; 9 (12)

  Abstract

  BACKGROUND: There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.RESULTS: The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.CONCLUSIONS: There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.CLINICAL RELEVANCE: Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

  View details for DOI 10.2106/JBJS.RVW.21.00065

  View details for PubMedID 34936580

• Provider Personal and Demographic Characteristics and Patient Satisfaction in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Lu, L. Y., Sharabianlou Korth, M. J., Cheng, R. Z., Finlay, A. K., Kamal, R. N., Goodman, S. B., Maloney, W. J., Huddleston, J. I., Amanatullah, D. F. 2021; 5 (4)

  Abstract

  INTRODUCTION: Patient satisfaction has increasingly been used to assess physician performance and quality of care. Although there is evidence that patient satisfaction is associated with patient-reported health outcomes and communication-related measures, there is debate over the use of patient satisfaction in reimbursement policy. Patient characteristics that influence satisfaction have been studied, but the effects of personal and demographic characteristics of physicians on patient satisfaction have yet to be explored.METHODS: Outpatient satisfaction scores from 11,059 patients who rated 25 orthopaedic surgeons from a single institution were studied. In this study, we sought to explore the relationship between nonmodifiable physician characteristics, such as sex and race, and patient satisfaction with outpatient orthopaedic surgery care, as expressed in the Press Ganey Satisfaction Scores. Univariate logistic regression models were used to test the associations between each provider characteristic and patient satisfaction on the Press Ganey patient satisfaction questionnaire.RESULTS: Three nonmodifiable physician personal and demographic characteristics were markedly associated with lower patient satisfaction scores across overall satisfaction, communication, and empathy domains: (1) female gender, (2) Asian ethnicity, and (3) being unmarried. Asian ethnicity reduced the odds of receiving a 5-star rating for likelihood to recommend the provider by nearly 40%, but none of these nonmodifiable physician personal and demographic characteristics affected the likelihood to recommend the practice.DISCUSSION: Sex, ethnicity, and marital status are nonmodifiable provider characteristics, each associated with markedly lower odds of receiving a 5-star rating on Press Ganey patient satisfaction survey. These data reveal inherent patient biases that negatively affect physician-patient interactions and may exacerbate the lack of diversity in orthopaedic surgery. More research is necessary before using patient satisfaction ratings to evaluate surgeons or as quality measures that affect reimbursement policies.

  View details for DOI 10.5435/JAAOSGlobal-D-20-00198

  View details for PubMedID 33835991

• Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release. The Journal of bone and joint surgery. American volume Barnes, J. I., Paci, G. n., Zhuang, T. n., Baker, L. C., Asch, S. M., Kamal, R. N. 2021; 103 (4): 343–55

  Abstract

  Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.19.01354

  View details for PubMedID 33591684

• Outcomes of Supplementary Spring Wire Fixation With Volar Plating for Volar Lunate Facet Fragments in Distal Radius Fractures. Hand (New York, N.Y.) Fogel, N., Shapiro, L. M., Roe, A., Denduluri, S., Richard, M. J., Kamal, R. N. 2020: 1558944720976404

  Abstract

  BACKGROUND: Intra-articular distal radius fractures with small volar lunate facet fragments can be challenging to address with volar plate fixation alone. Volar locked plating with supplementary spring wire fixation has been previously described in a small series but has not been further described in the literature. We hypothesized that this technique can provide adequate fixation for volar lunate facet fragments smaller than 15 mm in length, which are at risk of displacement.METHODS: We completed a retrospective chart review (2015-2019) of patients who underwent volar locked plating with the addition of supplementary spring wire fixation for intra-articular distal radius fractures with a volar lunate facet fragment (<15 mm). Postoperative radiographs were assessed to evaluate union, evidence of hardware failure, escape of the volar lunate facet fragment, and postoperative volar tilt. Clinical outcome was assessed with wrist flexion/extension, arc of pronosupination, and Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH) scores.RESULTS: Fifteen patients were identified, of which all went on to fracture union. There were no hardware failures or escape of the volar lunate facet fragment at final follow-up. One patient underwent hardware removal for symptoms of flexor tendon irritation. The mean wrist flexion was 59°, wrist extension was 70°, pronation was 81°, and supination was 76°. The mean QuickDASH score was 18.5. The mean postoperative volar tilt was 3.6°.CONCLUSIONS: Supplementary spring wire fixation with standard volar plating provides stable fixation for lunate facet fragments less than 15 mm. This technique is a safe and reliable alternative to commercially available fragment-specific implants.

  View details for DOI 10.1177/1558944720976404

  View details for PubMedID 33319593

• Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial. Clinical orthopaedics and related research Mariano, D. J., Liu, A., Eppler, S. L., Gardner, M. J., Hu, S., Safran, M., Chou, L., Amanatullah, D. F., Kamal, R. N. 2020

  Abstract

  BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs.QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions?METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement.RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71.CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000001582

  View details for PubMedID 33239521

• Candidate Quality Measures for Orthopaedic Surgery Outreach Trips: A Systematic Review. The Journal of the American Academy of Orthopaedic Surgeons Shapiro, L. M., Park, M. O., Mariano, D. J., Welch, J. M., Kamal, R. N. 2020

  Abstract

  INTRODUCTION: Up to 30% of the global burden of disease is secondary to surgical conditions, most of which falls on those in low- and middle-income countries (LMICs). Ensuring that the quality of care delivered during outreach trips to address these conditions is foundational. Limited work has been done to develop and implement tools to assess and improve the quality of care for these trips. The purpose of this study was to identify candidate quality measures that address orthopaedic surgery outreach trips in LMICs.METHODS: We conducted a systematic review of MEDLINE/PubMed, EMBASE, Web of Science, Google Scholar, and other databases to identify candidate quality measures relevant to orthopaedic surgery outreach to LMICs. Quality measures were then categorized by system management, sustainability, or both system management and sustainability according to the framework and structures, processes, and outcomes of Bido et al according to the Donabedian domains.RESULTS: Our initial search yielded 3,891 articles, 22 of which met the inclusion criteria. Seventy-nine candidate quality measures were identified. Regarding the framework of Bido et al, 55 of 79 (70%) were related to system management, 8 (10%) were related to sustainability, and 16 (20%) were related to both system management and sustainability. According to Donabedian domains, 43 of 79 (54%) were structure measures, 25 (32%) were process measures, and 11 (14%) were outcome measures.DISCUSSION: Quality measures addressing orthopaedic surgery outreach trips are lacking in quantity and breadth, limiting the ability to assess and improve the safety and quality of care provided. The candidate quality measures identified disproportionately focus on systems management and structures, with few related to sustainability and few addressing outcomes. Patients receiving care on outreach trips would benefit from the implementation of the measures identified in this review and from the development of quality measures that capture all domains of care and emphasize outcomes.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.5435/JAAOS-D-20-00263

  View details for PubMedID 34525479

• The Patient Perspective on Patient-Reported Outcome Measures Following Elective Hand Surgery: A Convergent Mixed-Methods Analysis. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Roe, A. K., Morris, A., Kamal, R. N. 2020

  Abstract

  PURPOSE: Patient-reported outcome measures (PROMs) have traditionally been used for research purposes, but are now being used to evaluate outcomes from the patient's perspective and inform ongoing management and quality of care. We used quantitative and qualitative approaches to evaluate the short-version Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Specific Functional Scale (PSFS) with regard to patient preference and measurement of patient goals and their responsiveness after treatment.METHODS: Patients 18 years or older undergoing elective hand surgery received the QuickDASH and PSFS questionnaires before and at 6 weeks after surgery. Two additional questions intended to elicit patients' preferences regarding the QuickDASH and PSFS were included. Responsiveness was measured by change in pre- to postoperative score. We analyzed patients' responses to the 2 additional questions to identify themes in PROM preferences. Results from the quantitative and qualitative analyses were combined into a convergent mixed-methods (eg, quantitative and qualitative) analysis.RESULTS: Thirty-eight patients completed preoperative questionnaires; 25 (66%) completed postoperative questionnaires. Seventeen patients (77%) preferred the PSFS, 3 (14%) had no preference, 2 (9%) preferred the QuickDASH. The average change from pre- to postoperative QuickDASH was -10 (SD, 20), and that of the PSFS was -27 (SD, 26). Ten patients (40%) reported QuickDASH score changes above the minimal clinically importance difference (MCID), 17 patients (68%) reported PSFS score changes above the MCID. Content analysis revealed 4 themes in preference for a PROM: instrument simplicity (ease of instrument understanding and completion), personalized assessment (individualization and relevance), goal directed (having measurable aims or objectives), distinct items (concrete or specific instrument items or functions).CONCLUSIONS: Most patients felt the PSFS better measured their goals because it is a simple, personalized instrument with distinct domains.CLINICAL RELEVANCE: Whereas standardized PROMs may better compare across populations, physicians, or conditions, employing PROMs that address patient-specific goals may better assess aspects of care most important to patients. A combination of these 2 types of PROMs can be used to assess outcomes and inform quality of care.

  View details for DOI 10.1016/j.jhsa.2020.09.008

  View details for PubMedID 33183858

• Can upstream patient education improve fracture care in a digital world? Use of a decision aid for the treatment of displaced diaphyseal clavicle fractures. Journal of orthopaedic trauma Lai, C. H., DeBaun, M. R., Van Rysselberghe, N., Abrams, G. D., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  BACKGROUND: The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCF) are ideal for a targeted intervention as there is no superior treatment, and decisions are often dependent on patient preference. A decision aid provided prior to consultation may educate a patient and minimize decisional conflict similarly to in-person consultation with an orthopaedic traumatologist.METHODS: Patients with DDCF were enrolled into two groups. The usual care group participated in a discussion with a trauma fellowship trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with International Patient Decision Aid Standards. Primary comparisons were made based on decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.RESULTS: A total of 41 patients enrolled. Decisional conflict scores were similar and low between the two groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.DISCUSSION: Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid prior to consultation may help incorporate patient values and preferences into the decision-making process between surgery and non-operative management.LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1097/BOT.0000000000001916

  View details for PubMedID 33105455

• Outcome Metrics in the Treatment of Carpal Tunnel Syndrome: A Systematic Review. Hand (New York, N.Y.) Mertz, K., Lindsay, S. E., Morris, A., Kamal, R. N. 2020: 1558944720949951

  Abstract

  BACKGROUND: The purpose of this systematic review was to determine the metrics used to assess outcomes after treatment for carpal tunnel syndrome.METHODS: We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of level I and II randomized controlled trials of treatment for carpal tunnel syndrome. We searched the PubMed/MEDLINE electronic database for studies on treatment of carpal tunnel syndrome from January 2008 to January 2018. A total of 105 studies were included in the final analysis. The metrics used to assess outcomes in each studies were collected, compared, and described.RESULTS: Nearly all the studies used a patient-reported outcome measure (PROM) to assess outcomes (94%). The most common PROMs used were the Boston Carpal Tunnel Questionnaire (60%) and the Visual Analog Scale for pain (51%). Electrophysiological testing and physical examination were also commonly used to assess outcomes (50% and 46%, respectively). Cost, sleep, and return to activities of daily living were assessed in a minority of studies (1%, 1%, and 5%, respectively).CONCLUSIONS: Successful treatment of carpal tunnel syndrome is commonly defined based on a PROM, highlighting recent efforts to measure outcomes from the patient's perspective. Other patient-centered metrics such as return to work and sleep quality, however, were rarely reported, whereas objective measures such as nerve conduction studies were prevalent. Further work is needed to determine patients' preferred method of measuring outcomes after treatment for carpal tunnel syndrome to inform goal-directed decision-making and treatment.

  View details for DOI 10.1177/1558944720949951

  View details for PubMedID 33073583

• A Cost-Effectiveness Analysis of Smoking-Cessation Interventions Prior to Posterolateral Lumbar Fusion. The Journal of bone and joint surgery. American volume Zhuang, T., Ku, S., Shapiro, L. M., Hu, S. S., Cabell, A., Kamal, R. N. 2020

  Abstract

  BACKGROUND: Smoking cessation represents an opportunity to reduce both short and long-term effects of smoking on complications after lumbar fusion and smoking-related morbidity and mortality. However, the cost-effectiveness of smoking-cessation interventions prior to lumbar fusion is not fully known.METHODS: We created a decision-analytic Markov model to evaluate the cost-effectiveness of 5 smoking-cessation strategies (behavioral counseling, nicotine replacement therapy [NRT], bupropion or varenicline monotherapy, and a combined intervention) prior to single-level, instrumented lumbar posterolateral fusion (PLF) from the health payer perspective. Probabilities, costs, and utilities were obtained from published sources. We calculated the costs and quality-adjusted life years (QALYs) associated with each strategy over multiple time horizons and accounted for uncertainty with probabilistic sensitivity analyses (PSAs) consisting of 10,000 second-order Monte Carlo simulations.RESULTS: Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon. In the short term, behavioral counseling, NRT, varenicline monotherapy, and the combined intervention were also cost-saving, while bupropion monotherapy was more effective but more costly than usual care. The mean lifetime cost savings for behavioral counseling, NRT, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291 (standard deviation [SD], $868), $2,571 (SD, $479), $2,851 (SD, $830), $6,767 (SD, $1,604), and $34,923 (SD, $4,248), respectively. The minimum efficacy threshold (relative risk for smoking cessation) for lifetime cost savings varied from 1.01 (behavioral counseling) to 1.15 (varenicline monotherapy). A PSA revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.CONCLUSIONS: Even brief smoking-cessation interventions yield large short-term and long-term cost savings. Smoking-cessation interventions prior to PLF can both reduce costs and improve patient outcomes as health payers/systems shift toward value-based reimbursement (e.g., bundled payments) or population health models.LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.20.00393

  View details for PubMedID 33038088

• The Importance of Concordance Between Patients and Their Subspecialists ORTHOPEDICS Shah, R. F., Mertz, K., Gil, J. A., Eppler, S. L., Amanatullah, D., Yao, J., Chou, L., Steffner, R., Safran, M., Hu, S. S., Kamal, R. N. 2020; 43 (5): 315-+

  Abstract

  Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient-physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient-physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315-319.].

  View details for DOI 10.3928/01477447-20200818-01

  View details for Web of Science ID 000608158400032

  View details for PubMedID 32931591

• National Trends in the Surgical Treatment of Chronic Rotator Cuff Tear in Patients Without Arthritis ORTHOPEDICS Vora, M., Sing, D. C., Curry, E. J., Kamal, R. N., Li, X. 2020; 43 (5): E409–E414

  Abstract

  Both rotator cuff repair (RCR) and reverse total shoulder arthroplasty (RTSA) are effective treatment options for chronic large degenerative rotator cuff tear (RCT) in the elderly. The goal of this study was to evaluate national trends for surgical management of chronic RCT among patients without glenohumeral arthritis. The authors conducted a retrospective review from 2007 to 2015 using the PearlDiver database. The study included patients who had the International Classification of Diseases, Ninth Revision, diagnosis of chronic RCT without shoulder arthritis. Procedural codes from the Current Procedural Terminology and the International Classification of Diseases, Ninth Revision, were used to identify patients undergoing RCR or RTSA. Chi-square analysis assessed differences between the groups, and Cochran-Armitage trend tests were used to evaluate trends over time. Overall, 428,651 patients had chronic RCT without arthritis; 364,141 (84.9%) were treated nonoperatively, 53,566 (12.5%) underwent RCR, and 10,944 (2.6%) underwent RTSA. Patients who were 60 to 79 years old had the highest rate of surgical intervention (70.8% of all surgical patients), with 69.2% and 78.4% who underwent RCR and RTSA, respectively. A 3-fold increase in RTSA use was noted among patients 60 years and older vs patients younger than 60 years. Overall revision rates 2 years after RCR and RTSA among patients 60 to 79 years old were 13.0% and 3.7%, respectively. Revision rates after RCR remained constant over time (9.3% to 13.0%; P=.082), whereas revision rates after RTSA decreased significantly over time (12.1% to 2.2%; P=.016). Older patients were more likely to be treated nonoperatively compared with younger patients, but among those patients treated with RTSA, there was a 3-fold increase in the use of RTSA in patients older than 60 years compared with patients younger than 60 years. Further, the authors found that revision rates after RTSA decreased over time (from 12% to 2%), suggesting better implant design, improved knowledge of implant positioning, and increased surgical proficiency. [Orthopedics. 2020;43(5):e409-e414.].

  View details for DOI 10.3928/01477447-20200619-09

  View details for Web of Science ID 000608158400011

  View details for PubMedID 32602925

• A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial. Medical decision making : an international journal of the Society for Medical Decision Making Mertz, K., Shah, R. F., Eppler, S. L., Yao, J., Safran, M., Palanca, A., Hu, S. S., Gardner, M., Amanatullah, D. F., Kamal, R. N. 2020: 272989X20943520

  Abstract

  Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

  View details for DOI 10.1177/0272989X20943520

  View details for PubMedID 32744134

• Safety of Releasing the Volar Capsule During Open Treatment of Distal Radius Fractures: An Analysis of the Extrinsic Radiocarpal Ligaments' Contribution to Radiocarpal Stability. The Journal of hand surgery Suazo Gladwin, L. A., Douglass, N., Behn, A. W., Thio, T., Ruch, D. S., Kamal, R. N. 2020

  Abstract

  PURPOSE: The contribution of the extrinsic radiocarpal ligaments to carpal stability continues to be studied. Clinically, there is a concern for carpal instability from release of the volar extrinsic ligaments during volar plating of distal radius fractures in which the integrity of the dorsal ligaments may be unknown. The primary hypothesis of this study was that serial sectioning of radiocarpal ligaments would lead to progressive ulnar translation of the carpus.METHODS: We studied the stabilizing roles of the radioscaphocapitate (RSC), short radiolunate (SRL), long radiolunate (LRL), and dorsal radiocarpal (DRC) ligaments. We sequentially sectioned these ligaments in 2 groups of 5 matched pairs and measured the motion of the scaphoid and lunate with the wrist in passive neutral alignment, radial deviation, ulnar deviation, and simulated grip. Displacement of the lunate in the radioulnar plane was used as a surrogate for carpal translation. The groups differed only by the order in which the ligaments were sectioned.RESULTS: In the intact state, the lunate translated ulnarly during simulated grip and radial deviation, whereas radial translation, relative to its position under resting tension, was observed during ulnar deviation. With serial sectioning, the lunate displayed increased ulnar translation in all wrist positions for both groups 1 and 2. The magnitude of ulnar translation exceeded 1 mm after sectioning the LRL plus RSC along with either the DRC or the SRL.CONCLUSIONS: Sectioning of either the DRC or SRL ligaments along with release of the RSC and LRL ligaments leads to notable although minimal (<2-mm) ulnar lunate translation.CLINICAL RELEVANCE: Isolated sectioning of individual radiocarpal ligaments, such as for visualization of the articular surface of the distal radius, leads to minimal ulnar translation. Because prior clinical work found no clinical complications after volar capsule release, it is posited that translation less than 2 mm creates subclinical changes in carpal mechanics.

  View details for DOI 10.1016/j.jhsa.2020.05.022

  View details for PubMedID 32747049

• The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study. The Journal of hand surgery Zhuang, T., Kortlever, J. T., Shapiro, L. M., Baker, L., Harris, A. H., Kamal, R. N. 2020

  Abstract

  PURPOSE: To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS).METHODS: We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale.RESULTS: Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n= 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions.CONCLUSIONS: Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS.CLINICAL RELEVANCE: Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.

  View details for DOI 10.1016/j.jhsa.2020.05.019

  View details for PubMedID 32723572

• Feasibility of Quality Measures for the Diagnosis and Treatment of Carpal Tunnel Syndrome. The Journal of hand surgery Crijns, T. J., Ring, D., Leung, N., Kamal, R. N., AAOS and ASSH Carpal Tunnel Quality Measures Workgroup 2020

  Abstract

  PURPOSE: The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures.METHODS: Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval.RESULTS: A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85).CONCLUSIONS: There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data.CLINICAL RELEVANCE: Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

  View details for DOI 10.1016/j.jhsa.2020.05.004

  View details for PubMedID 32723571

• Development and Testing of a Question Prompt List for Common Hand Conditions: An Exploratory Sequential Mixed-Methods Study. The Journal of hand surgery Satteson, E. S., Roe, A. K., Eppler, S. L., Yao, J., Shapiro, L. M., Kamal, R. N. 2020

  Abstract

  PURPOSE: A question prompt list (QPL) is a tool that lists possible questions a patient may want to ask their surgeon. Its purpose is to improve patient-physician communication and increase patient engagement. Although QPLs have been developed in other specialties, one does not exist for hand conditions. We sought to develop a QPL for use in the hand surgery clinic using a mixed-methods design.METHODS: We drafted a QPL based on prior work outside of hand surgery and then used an exploratory sequential mixed-methods design (both qualitative and quantitative methods) to finalize the QPL. Qualitative evaluation included both a written questionnaire completed by a patient advisory board, hand therapists, and hand surgeons, as well as cognitive interviews conducted with clinic patients using the tool. Revisions to the QPL were made after each phase of qualitative analysis. The final QPL was then evaluated quantitatively using the system usability score (SUS) questionnaire to assess its usability.RESULTS: A patient advisory board consisting of 6 patients, 5 hand therapists, and 6 hand surgeons completed the written questionnaire. Thirteen patients completed a cognitive interview of the QPL. We completed a content analysis of the qualitative data and incorporated the findings into the QPL. Twenty patients then reviewed the final QPL pamphlet and completed the SUS questionnaire. The resulting SUS score of 78.8 indicated above-average usability of the QPL tool.CONCLUSIONS: The QPL developed in this study, from the perspective of multiple stakeholders, provides a usable tool to engage and prompt patients in asking questions during their visit with their hand surgeon with the potential to improve communication and patient-centered care.CLINICAL RELEVANCE: This study provides clinicians with a QPL developed for use in the hand surgery clinic setting, aimed at facilitating more thorough patient-provider discussion.

  View details for DOI 10.1016/j.jhsa.2020.05.015

  View details for PubMedID 32693988

• Measuring and Improving the Quality of Care During Global Outreach Trips: A Primer for Safe and Sustainable Surgery. The Journal of hand surgery Shapiro, L. M., Global-Quest Investigators, Shapiro, L. M., Chang, J., Fox, P. M., Kozin, S. H., Chung, K. C., Dyer, G. S., Fufa, D. T., Leversedge, F. J., Katarincic, J. A., Kamal, R. N. 2020

  Abstract

  Trauma is the leading cause of mortality in patients aged 5 years and older. Globally, trauma kills more people than malaria, tuberculosis, and HIV/AIDs combined. As the number of surgical outreach trips to low- and middle-income countries and resources provided for such trips increase, hand surgeons are uniquely positioned to address this global burden. However, the delivery of surgical care alone is insufficient without effectively evaluating the quality of care delivered. It is critical that the care provided on outreach trips improves patient and population health, does not harm patients, and develops the local health care ecosystem. An estimated 8 million lives could be saved annually in low- and middle-income countries with higher-quality health systems. Currently, data collection systems for evaluating quality during outreach trips are lacking. Insight into current methods of quality assessment and improvement in both developing and developed countries can help inform future efforts to implement innovative data collection systems. Thoughtful and sustainable collaboration with host sites in low- and middle-income countries can ensure that care delivery is culturally competent and improves population health.

  View details for DOI 10.1016/j.jhsa.2020.04.027

  View details for PubMedID 32680787

• Rotational stability of scaphoid waist non-union bone graft and fixation techniques. The Journal of hand surgery Gire, J. D., Thio, T., Behn, A. W., Kamal, R. N., Ladd, A. L. 2020

  Abstract

  PURPOSE: Rotational instability of scaphoid fracture nonunions can lead to persistent nonunion. We hypothesized that a hybrid Russe technique would provide improved rotational stability compared with an instrumented corticocancellous wedge graft in a cadaver model of scaphoid nonunion.METHODS: A volar wedge osteotomy was created at the scaphoid waist in 16 scaphoids from matched-pair specimens. A wedge was inset at the osteotomy site or a 4* 16-mm strut was inserted in the scaphoid and a screw was placed along the central axis (model 1). The construct was cyclically loaded in torsion until failure. The screw was removed and the proximal and distal poles were debrided. A matching wedge and packed cancellous bone graft or an 8* 20-mm strut was shaped and fit inside the proximal and distal pole (model 2). A screw was placed and testing was repeated.RESULTS: In the first model, there was no significant difference in cycles to failure, target torque, or maximal torque between the strut graft and the wedge graft. Cycles to failure positively correlated with estimated bone density for the wedge graft, but not for the strut graft. In the second model, the strut graft had significantly higher cycles to failure, greater target torque, and higher maximal torque compared with the wedge graft. The number of cycles to failure was not correlated with estimated bone density for the wedge or the strut grafts.CONCLUSIONS: The hybrid Russe technique of inlay corticocancellous strut and screw fixation provides improved rotational stability compared with a wedge graft with screw fixation for a cadaver model of scaphoid waist nonunion with cystic change.CLINICAL RELEVANCE: The hybrid Russe technique may provide better rotational stability for scaphoid waist nonunions when the proximal or distal scaphoid pole is compromised, such as when there is extensive cystic change, when considerable debridement is necessary, or with revision nonunion surgery.

  View details for DOI 10.1016/j.jhsa.2020.05.012

  View details for PubMedID 32654765

• Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. The Journal of hand surgery Wu, E. J., Zhang, S. E., Truntzer, J. N., Gardner, M. J., Kamal, R. N. 2020

  Abstract

  PURPOSE: Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures.METHODS: We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis.RESULTS: Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased.CONCLUSIONS: Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis IV.

  View details for DOI 10.1016/j.jhsa.2020.03.022

  View details for PubMedID 32482497

• Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clinics in sports medicine Shapiro, L. M., Kamal, R. N. 2020; 39 (2): 279–97

  Abstract

  Flexor tendon and pulley injuries in athletes present a unique challenge to the treating clinician. An understanding of the anatomy and mechanism of injury helps the clinician appropriately diagnose and treat the injury. Treatment may become more complicated when associated with delays in diagnosis, in-season considerations, and an athlete's desire to return to play. Two injuries involving the flexor tendon-pulley system, avulsion injuries of the flexor digitorum profundus tendon from its insertion onto the base of the distal phalanx and flexor pulley injuries, are examined in detail in this article.

  View details for DOI 10.1016/j.csm.2019.12.004

  View details for PubMedID 32115085

• Clinical and Patient-Reported Outcomes After Hybrid Russe Procedure for Scaphoid Nonunion. Hand (New York, N.Y.) Shapiro, L. M., Roe, A. K., Kamal, R. N. 2020: 1558944720911214

  Abstract

  Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved -17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

  View details for DOI 10.1177/1558944720911214

  View details for PubMedID 32188288

• Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (New York, N.Y.) Ding, Q., Trickey, A. W., Mudumbai, S., Kamal, R. N., Sears, E. D., Harris, A. H. 2020: 1558944720906498

  Abstract

  Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

  View details for DOI 10.1177/1558944720906498

  View details for PubMedID 32100568

• A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger. The Journal of hand surgery Zhuang, T. n., Wong, S. n., Aoki, R. n., Zeng, E. n., Ku, S. n., Kamal, R. N. 2020

  Abstract

  To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs.Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy.Economic and Decision Analyses II.

  View details for DOI 10.1016/j.jhsa.2020.04.008

  View details for PubMedID 32471754

• Quality Measures to Deliver Safe, High-Quality Care on Hand Surgery Outreach Trips to Low and Middle-Income Countries. The Journal of bone and joint surgery. American volume Shapiro, L. M. 2020; Publish Ahead of Print

  Abstract

  The burden of hand surgery in low and middle-income countries (LMICs) is immense and growing. Although outreach trips to LMICs have been increasing, there has remained a gap regarding assessment of quality of care on outreach trips. We developed quality measures to assess hand surgery outreach trips to LMICs.We followed the recommendations set forth by the World Health Organization for practice guideline development. We used the results of a systematic review to inform the development of quality measures. Eight hand and upper-extremity surgeons with extensive global outreach experience (mean surgical outreach experience of >15 years, completed >3,000 surgeries in 24 countries) completed a modified RAND/UCLA (University of California Los Angeles) Delphi process to evaluate the importance, the feasibility, the usability, and the scientific acceptability of 83 measures. Validity was defined according to established methods.A tiering system that was based on the resources available at an outreach site (essential, intermediate, and advanced) was developed to classify the application of the measures since care delivery in LMICs often is constrained by local resources. Twenty-two (27%) of 83 measures were validated. All 22 (100%) were classified as essential (e.g., availability of interpretation services for the visiting team); no measures that were classified as intermediate or advanced were validated.Field-testing and implementation of quality measures served to identify the safety and the quality of hand surgical care that was provided on outreach trips to LMICs and inform improvement efforts. Tiers of care can be applied to quality measures to incorporate resource and capacity limitations when assessing their performance.Ensuring safety and high-quality care on hand surgical outreach trips to LMICs is foundational to all participating organizations and physicians. Valid quality measures can be implemented by organizations undertaking outreach trips to LMICs.

  View details for DOI 10.2106/JBJS.19.01506

  View details for PubMedID 33337798

• Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Schultz, B. J., Tanner, N. n., Shapiro, L. M., Segovia, N. A., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

  View details for DOI 10.1053/j.jfas.2020.01.008

  View details for PubMedID 32173179

• Health Policy in Hand Surgery: Evaluating What Works. Hand clinics Shapiro, L. M., Kamal, R. N. 2020; 36 (2): 263–70

  Abstract

  Health policy is a complex and fluid topic that addresses care delivery with the goal of improving patient care. Understanding health policy initiatives, their motivation, and their effects, can help ensure hand surgeons are prepared for the changing health care landscape.

  View details for DOI 10.1016/j.hcl.2020.01.009

  View details for PubMedID 32307057

• Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability. BMC health services research Harris, A. H., Meerwijk, E. L., Ding, Q. n., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Nuckols, T. K., Kamal, R. N. 2020; 20 (1): 861

  Abstract

  The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures.The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center.The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively).Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

  View details for DOI 10.1186/s12913-020-05704-6

  View details for PubMedID 32917188

• Decompression With or Without Fusion for Lumbar Stenosis: A Cost Minimization Analysis. Spine Ziino, C. n., Mertz, K. n., Hu, S. n., Kamal, R. n. 2020; 45 (5): 325–32

  Abstract

  Retrospective database review.Compare 1-year episode of care costs between single-level decompression and decompression plus fusion for lumbar stenosis.Lumbar stenosis is the most common indication for surgery in patients over 65. Medicare direct hospital costs for lumbar surgery reached $1.65 billion in 2007. Despite stenosis being a common indication for surgery, there is debate as to the preferred surgical treatment. Cost-minimization analysis is a framework that identifies potential cost savings between treatment options that have similar outcomes. We performed a cost-minimization analysis of decompression versus decompression with fusion for lumbar stenosis from the payer perspective.An administrative claims database of privately insured patients (Humana) identified patients who underwent decompression (n = 5349) or decompression with fusion (n = 8540) for lumbar stenosis with and without spondylolisthesis and compared overall costs. All patients were identified and costs identified for a 1-year period. Complication rates and costs were described using summary statistics.Mean treatment costs at 1 year after surgery were higher for patients who underwent decompression and fusion compared to patients who underwent decompression alone ($20,892 for fusion vs. $6329 for decompression; P < 0.001). Facility costs (P < 0.001), surgeon costs (P < 0.001), and physical therapy costs (P < 0.001) were higher in the fusion group. Cost differences related to infection or durotomy reached significance (P < 0.04). No difference in cost was identified for supplies.Decompression had significantly lower costs for the treatment of lumbar stenosis, including treatment for postoperative complications. If cost minimization is the primary goal, decompression is favored for surgical treatment of lumbar stenosis. Other factors including shared decision-making directed toward patient's values, patient-reported outcomes, and preferences should also be recognized as drivers of healthcare decisions.3.

  View details for DOI 10.1097/BRS.0000000000003250

  View details for PubMedID 32045402

• Development of a Needs Assessment Tool to Promote Capacity Building in Hand Surgery Outreach Trips: A Methodological Triangulation Approach. The Journal of hand surgery Shapiro, L. M., Park, M. O., Mariano, D. J., Kamal, R. N. 2020

  Abstract

  The surgical burden in low- and middle-income countries (LMIC) is immense. Despite the increase in resources invested in surgical outreach trips to LMIC, there is no consistent process for understanding the needs of the site and for preparing the necessary resources to deliver care. Given the importance and lack of a comprehensive and standardized needs assessment tool, we aimed to create a tool that assesses the needs and capacity of a site to inform site selection and expectations and improve quality of care.We used methodological triangulation, a technique that incorporates multiple and different types of data collection methods to study a phenomenon. We used 2 standardized World Health Organization (WHO) tools to develop a hand surgery-specific needs assessment tool. We then identified missing items and made refinements as a result of field testing at 2 facilities and qualitative analysis of semistructured interviews of hand surgeons with international outreach experience. Interviews were coded and analyzed using conductive content analysis. Key concepts explored included domains and subdomains pertaining to essential considerations prior to a hand surgery outreach trip.Current generic needs assessment tools do not capture all necessary domains and subdomains for a hand surgery outreach trip. The WHO tools provide a framework for reference and foundation; field testing and qualitative interviews identified hand surgery-specific items. We developed a tool (https://sustainableglobalsurgery.org/research%2Ftools) that includes 7 domains: (1) human resources; (2) physical resources; (3) procedures; (4) cultural and language barriers; (5) safety, quality, and access; (6) regulation and cost; and (7) knowledge transfer and teaching and associated subdomains relevant to hand surgery.A hand surgery-specific standardized needs assessment tool may ensure appropriate resources and personnel are deployed for outreach trips to improve site selection, expectation setting, and quality of care.A needs assessment tool is a standardized, comprehensive tool to assess the needs and capacity of a new site prior to hand surgery outreach trips to improve site selection, expectation setting, and delivery of high-quality, safe, and effective care in LMIC.

  View details for DOI 10.1016/j.jhsa.2020.04.014

  View details for PubMedID 32561162

• Deciding Without Data: Clinical Decision Making in Pediatric Orthopaedic Surgery. International journal for quality in health care : journal of the International Society for Quality in Health Care Nathan, K. n., Uzosike, M. n., Sanchez, U. n., Karius, A. n., Leyden, J. n., Nicole, S. n., Sara, E. n., Hastings, K. G., Kamal, R. n., Frick, S. n. 2020

  Abstract

  Objective.Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision making, national guidelines, and clinical pathways for many conditions in pediatric orthopaedic surgery are limited. This study investigated decision making rationale and quantified the evidence supporting decisions made by pediatric orthopaedic surgeons in an outpatient clinic.Design/Setting/Participants/Intervention(s)/Main Outcome Measure(s).We recorded decisions made by eight pediatric orthopaedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. "Experience/anecdote", "First Principles", "Trained to do it", "Arbitrary/Instinct", "General Study", "Specific Study").Results.Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were "First principles" (N=310, 27.0%) and "Experience/anecdote" (N=253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.Conclusions.With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence, and help create clinical care pathways in pediatric orthopaedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools & aids could also be implemented to guide these decisions.

  View details for DOI 10.1093/intqhc/mzaa119

  View details for PubMedID 32986101

• Maximization Personality, Disability and Symptoms of Psychosocial Disease in Hand Surgery Patients. Journal of surgical orthopaedic advances Gire, J., Alokozai, A., Sheikholeslami, N., Lindsay, S., Eppler, S. L., Kamal, R. N. 2020; 29 (2): 106–11

  Abstract

  There are different frameworks to describe how people make decisions. One framework, maximization, is an approach where individuals approach choices with a goal of finding the 'best' possible alternative. We sought to determine the relationship between maximization and patient reported disability in patients with hand problems. We performed a cross-sectional study of 119 patients who presented to a hand surgery clinic. Patients completed a questionnaire that included sociodemographics, QuickDASH, Decisional Conflict Scale, Pain Catastrophizing Scale, Patient Health Questionnaire, Health Anxiety Inventory and General Self-Efficacy. Maximization did not correlate with subjective disability in patients with hand problems. Depression, pain catastrophizing and a diagnosis of upper extremity fracture had the greatest independent association with disability.In patients presenting for an initial hand surgery consultation, maximization was not associated with variation in patient reported disability or symptoms of psychosocial disease. Alternative factors influencing patient decision-making and outcomes should be explored. (Journal of Surgical Orthopaedic Advances 29(2):106-111, 2020).

  View details for PubMedID 32584225

• The Relationship Between the Tensile and the Torsional Properties of the Native Scapholunate Ligament and Carpal Kinematics. The Journal of hand surgery Pang, E. Q., Douglass, N., Behn, A., Winterton, M., Rainbow, M. J., Kamal, R. N. 2019

  Abstract

  PURPOSE: The purpose of this exploratory study was to examine the relationship between the tensile and the torsional properties of the native scapholunate interosseous ligament (SLIL) and kinematics of the scaphoid and lunate of an intact wrist during passive radioulnar deviation.METHODS: Eight fresh-frozen cadaveric specimens were transected at the elbow joint and loaded into a custom jig. Kinematic data of the scaphoid and lunate were acquired in a simulated resting condition for 3 wrist positions-neutral, 10° radial deviation, and 30° ulnar deviation-using infrared-emitting rigid body trackers. The SLIL bone-ligament-bone complex was then resected and loaded on a materials testing machine. Specimens underwent cyclic torsional and tensile testing and SLIL tensile and torsional laxity were evaluated. Correlations between scaphoid and lunate rotations and SLIL tensile and torsional properties were determined using Pearson correlation coefficients.RESULTS: Ulnar deviation of both the scaphoid and the lunate were found to decrease as the laxity of SLIL in torsion increased. In addition, the ratio of lunate flexion-extension to radial-ulnar deviation was found to increase with increased SLIL torsional rotation.CONCLUSIONS: Our findings support the theory that there is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments.CLINICAL RELEVANCE: Laxity and, specifically, the tensile and torsional properties of an individual's native SLIL should guide reconstruction using a graft material that more closely replicates the individual's native SLIL properties.

  View details for DOI 10.1016/j.jhsa.2019.10.024

  View details for PubMedID 31864824

• Patient Willingness to Pay for Faster Return to Work or Smaller Incisions. Hand (New York, N.Y.) Alokozai, A., Lindsay, S. E., Eppler, S. L., Fox, P. M., Ladd, A. L., Kamal, R. N. 2019: 1558944719890039

  Abstract

  Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

  View details for DOI 10.1177/1558944719890039

  View details for PubMedID 31791156

• Physical and Occupational Therapy Use and Cost After Common Hand Procedures. The Journal of hand surgery Shah, R. F., Zhang, S., Li, K., Baker, L., Sox-Harris, A., Kamal, R. N. 2019

  Abstract

  PURPOSE: The use of routine physical therapy (PT) and occupational therapy (OT) after certain hand procedures, such as carpal tunnel release, remains controversial. The objective of this study was to evaluate baseline use, the change in use, variation in prescribing patterns by region, and costs for PT/OT after common hand procedures.METHODS: Outpatient administrative claims data from patients who underwent procedures for carpal tunnel syndrome, trigger finger, carpometacarpal arthritis, de Quervain tenosynovitis, wrist ganglion cyst, and distal radius fracture were abstracted from the Truven Health MarketScan database from 2007 to 2015. The incidence of therapy and total reimbursement of therapy per patient were collected for each procedure over a 90-day postoperative observational period. Trends in use of therapy over time were described with average compound annual growth rates (CAGRs), a way of quantifying average growth over a specified observation period. Variations in the incidence of PT/OT use across 4 census regions were assessed.RESULTS: The incidence of 90-day utilization of PT and OT after hand procedures was 14.0% and increased for all procedures during the observation period with an average CAGR of 8.3%. Cost per therapy visit was relatively stable when adjusted for inflation, with an average CAGR of 0.63%. Patients in the northeast had a significantly higher incidence of PT/OT use than those in the south and west for all procedures except carpometacarpal arthritis.CONCLUSIONS: Use of PT and OT has increased over time after common hand procedures. Geographical variation in the utilization rate of these services is substantial. Limiting unwarranted variation of care is a health policy strategy for increasing value of care.TYPE OF STUDY/LEVEL OF EVIDENCE: Outcomes Research II.

  View details for DOI 10.1016/j.jhsa.2019.09.008

  View details for PubMedID 31753716

• Performance Metrics in Hand Surgery: Turning a Blind Eye Will Cost You. The Journal of hand surgery Roe, A. K., Gil, J. A., Kamal, R. N. 2019

  Abstract

  The Medicare Access and Children's Health Insurance Program Reauthorization Act established the Quality Payment Program (QPP), which mandates that physicians who meet the threshold in volume of Medicare patients for whom they care participate in this program through either advanced Alternative Payment Models or the Merit-Based Incentive Payment System. Anticipating physicians' concerns regarding the burden of implementing the QPP, feedback from physicians became a critical component of the continued implementation process in 2018. The purpose of this review is to inform hand surgeons regarding the current QPP (early 2019) and for future observation periods.

  View details for DOI 10.1016/j.jhsa.2019.09.011

  View details for PubMedID 31740263

• Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study. Hand (New York, N.Y.) Burn, M. B., Shapiro, L. M., Eppler, S. L., Behal, R., Kamal, R. N. 2019: 1558944719884661

  Abstract

  Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

  View details for DOI 10.1177/1558944719884661

  View details for PubMedID 31690136

• Cost in Hand Surgery: The Patient Perspective JOURNAL OF HAND SURGERY-AMERICAN VOLUME Alokozai, A., Crijns, T. J., Janssen, S. J., Van der Gronde, B., Ring, D., Sox-Harris, A., Kamal, R. N. 2019; 44 (11)

  View details for DOI 10.1016/j.jhsa.2019.01.009

  View details for Web of Science ID 000493892500015

• Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (New York, N.Y.) Kortlever, J. T., Zhuang, T., Ring, D., Reichel, L. M., Vagner, G. A., Kamal, R. N. 2019: 1558944719873399

  Abstract

  Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.

  View details for DOI 10.1177/1558944719873399

  View details for PubMedID 31517517

• The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for DistalRadius Fractures in Patients 55Years andOlder. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Baker, L. C., Harris, A. S., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years.METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility.RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year.CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed.CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

  View details for DOI 10.1016/j.jhsa.2019.07.010

  View details for PubMedID 31495523

• Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019; 129 (3): 804-811

  Abstract

  The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

  View details for DOI 10.1213/ANE.0000000000004291

  View details for PubMedID 31425223

• The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review. JBJS reviews Shapiro, L. M., Zhuang, T., Li, K., Kamal, R. N. 2019

  View details for DOI 10.2106/JBJS.RVW.18.00168

  View details for PubMedID 31436581

• Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions. Hand (New York, N.Y.) Zhuang, T., Eppler, S. L., Shapiro, L. M., Roe, A. K., Yao, J., Kamal, R. N. 2019: 1558944719866889

  Abstract

  Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

  View details for DOI 10.1177/1558944719866889

  View details for PubMedID 31409138

• Differences in the Rotation Axes of the Scapholunate Joint During Flexion-Extension and Radial-Ulnar Deviation Motions. The Journal of hand surgery Best, G. M., Mack, Z. E., Pichora, D. R., Crisco, J. J., Kamal, R. N., Rainbow, M. J. 2019

  Abstract

  PURPOSE: To determine the location of the rotation axis between the scaphoid and the lunate (SL-axis) during wrist flexion-extension (FE) and radial-ulnar deviation (RUD).METHODS: An established and publicly available digital database of wrist bone anatomy and carpal kinematics of 30 healthy volunteers (15 males and 15 females) in up to 8 different positions was used to study the SL-axis. Using the combinations of positions from wrist FE and RUD, the helical axis of motion of the scaphoid relative to the lunate was calculated for each trial in an anatomical coordinate system embedded in the lunate. The differences in location and orientation between each individual axis and the average axis were used to quantify variation in axis orientation. Variation in the axis location was computed as the distance from the closest point on the rotation axis to the centroid of the lunate.RESULTS: The variation in axis orientation of the rotation axis for wrist FE and RUD were 84.3° and 83.5°, respectively. The mean distances of each rotation axis from the centroid of the lunate for FE and RUD were 5.7 ± 3.2 mm, and 5.0 ± 3.6 mm, respectively.CONCLUSIONS: Based on the evaluation of this dataset, we demonstrated that the rotation axis of the scaphoid relative to the lunate is highly variable across subjects and positions during both FE and RUD motions. The range of locations and variation in axis orientations in this data set of 30 wrists shows that there is very likely no single location for the SL-axis.CLINICAL RELEVANCE: Scapholunate interosseous ligament reconstruction methods focused on re-creating a standard SL-axis may not restore what is more likely to be a variable anatomical axis and normal kinematics of the scaphoid and lunate.

  View details for DOI 10.1016/j.jhsa.2019.05.001

  View details for PubMedID 31300230

• The Role of Patient Research in Patient Trust in Their Physician JOURNAL OF HAND SURGERY-AMERICAN VOLUME Lu, L. Y., Sheikholeslami, N., Alokozai, A., Eppler, S. L., Kamal, R. N. 2019; 44 (7): 617-+

  View details for DOI 10.1016/j.jhsa.2018.09.007

  View details for Web of Science ID 000473318800017

• Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019

  Abstract

  BACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).METHODS: Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.RESULTS: From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

  View details for DOI 10.1213/ANE.0000000000004291

  View details for PubMedID 31206428

• The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger JOURNAL OF HAND SURGERY-AMERICAN VOLUME Shapiro, L. M., Eppler, S. L., Kamal, R. N. 2019; 44 (6): 480-+

  View details for DOI 10.1016/j.jhsa.2019.01.005

  View details for Web of Science ID 000469438800006

• The Association of Financial Distress With Disability in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Mertz, K., Eppler, S. L., Thomas, K., Alokozai, A., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. N. 2019; 27 (11): e522–e528

  Abstract

  INTRODUCTION: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?METHODS: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.RESULTS: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.CONCLUSIONS: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.LEVEL OF EVIDENCE: Level III prospective cohort.

  View details for DOI 10.5435/JAAOS-D-18-00252

  View details for PubMedID 31125323

• Can Patients Forecast Their Postoperative Disability and Pain? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Alokozai, A., Eppler, S. L., Lu, L. Y., Sheikholeslami, N., Kamal, R. N. 2019; 477 (3): 635–43

  View details for DOI 10.1097/CORR.0000000000000627

  View details for Web of Science ID 000472558500028

• Can Patients Forecast Their Postoperative Disability and Pain? Clinical orthopaedics and related research Alokozai, A., Eppler, S. L., Lu, L. Y., Sheikholeslami, N., Kamal, R. N. 2019; 477 (3): 635–43

  Abstract

  BACKGROUND: Forecasting is a construct in which experiences and beliefs inform a projection of future outcomes. Current efforts to predict postoperative patient-reported outcome measures such as risk-stratifying models, focus on studying patient, surgeon, or facility variables without considering the mindset of the patient. There is no evidence assessing the association of a patient's forecasted postoperative disability with realized postoperative disability. Patient-forecasted disability could potentially be used as a tool to predict postoperative disability.QUESTIONS/PURPOSES: (1) Do patient-forecasted disability and pain correlate with patient-realized disability and pain after hand surgery? (2) What other factors are associated with patient ability to forecast disability and pain?METHODS: We completed a prospective, longitudinal study to assess the association between forecasted and realized postoperative pain and disability as a predictive tool. One hundred eighteen patients of one hand/upper extremity surgeon were recruited from November 2016 to February 2018. Inclusion criteria for the study were patients undergoing hand or upper extremity surgery, older than 18 years of age, and English fluency and literacy. We enrolled 118 patients; 32 patients (27%) dropped out as a result of incomplete postoperative questionnaires. The total number of patients eligible was not tracked. Eighty-six patients completed the preoperative and postoperative questionnaires. Exclusion criteria included patients unable to give informed consent, children, patients with dementia, and nonEnglish speakers. Before surgery, patients completed a questionnaire that asked them to forecast their upper extremity disability (DASH [the shortened Disabilities of the Arm, Shoulder and Hand] [QuickDASH]) and pain VAS (pain from 0 to 10) for 2 weeks after their procedure. The questionnaire also queried the following psychologic factors as explanatory variables, in addition to other demographic and socioeconomic variables: the General Self Efficacy Scale, the Pain Catastrophizing Scale, and the Patient Health Questionnaire Depression Scale. At the 2-week followup appointment, patients completed the QuickDASH and pain VAS to assess their realized disability and pain scores. Bivariate analysis was used to test the association of forecasted and realized disability and pain reporting Pearson correlation coefficients. Unpaired t-tests were performed to test the association of demographic variables (for example, men vs women) and the association of forecasted and realized disability and pain levels. One-way analysis of variance was used for variables with multiple groups (for example, annual salary and ethnicity). All p values < 0.05 were considered statistically significant.RESULTS: Forecasted postoperative disability was moderately correlated with realized postoperative disability (r = 0.59; p < 0.001). Forecasted pain was weakly correlated with realized postoperative pain (r = 0.28; p = 0.011). A total of 47% of patients (n = 40) were able to predict their disability score within the MCID of their realized disability score. Symptoms of depression also correlated with increased realized postoperative disability (r = 0.37; p < 0.001) and increased realized postoperative pain (r = 0.42; p < 0.001). Catastrophic thinking was correlated with increased realized postoperative pain (r = 0.31; p = 0.004). Patients with symptoms of depression realized greater pain postoperatively than what they forecasted preoperatively (r = -0.24; p = 0.028), but there was no association between symptoms of depression and patients' ability to forecast disability (r = 0.2; p = 0.058). Patient age was associated with a patient's ability to forecast disability (r = .27; p = 0.011). Catastrophic thinking, self-efficacy, and number of prior surgical procedures were not associated with a patient's ability to forecast their postoperative disability or pain.CONCLUSIONS: Patients undergoing hand surgery can moderately forecast their postoperative disability. Surgeons can use forecasted disability to identify patients who may experience greater disability compared with benchmarks, for example, forecast and experience high QuickDASH scores after surgery, and inform preoperative discussions and interventions focused on expectation management, resilience, and mindset.LEVEL OF EVIDENCE: Level III, prognostic study.

  View details for PubMedID 30762696

• Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (New York, N.Y.) Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Marshall, N., Mudumbai, S. C. 2019: 1558944719828006

  Abstract

  BACKGROUND: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities.METHODS: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques.RESULTS: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients.CONCLUSIONS: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.

  View details for PubMedID 30789047

• The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Kamal, R. N. 2019

  Abstract

  PURPOSE: Shared decision making is an approach where physicians and patients collaborate to make decisions based on patient values. This requires eliciting patients' preferences for each treatment attribute before making decisions; a structured process for preference elicitation does not exist in hand surgery. We tested the feasibility and usability of a ranking tool to elicit patient preferences for the treatment of trigger finger. We hypothesized that the tool would be usable and feasible at the point of care.METHODS: Thirty patients with a trigger finger without prior treatment were recruited from a hand surgery clinic. A preference elicitation tool was created that presented 3 treatment options(surgical release, injection, and therapy and orthosis) and described attributes of each treatment extracted from literature review (eg, success rate, complications). We presented these attributes to patients using the tool and patients ranked the relative importance (preference)of these attributes to aid in their decision making. The System Usability Scale and tool completion time were used to evaluate usability and feasibility, respectively.RESULTS: The tool demonstrated excellent usability (System Usability Scale: 88.7). The mean completion time was 3.05 minutes. Five (16.7%) patients chose surgery, 20 (66.7%) chose an injection, and 5 (16.7%) chose therapy and orthosis. Patients ranked treatment success and cost as the most and least important attributes, respectively. Twenty-nine (96.7%) patients were very to extremely satisfied with the tool.CONCLUSIONS: A preference elicitation tool for patients to rank treatment attributes by relative importance is feasible and usable at the point of care. A structured process for preference elicitation ensures that patients understand the trade-offs between choices and can assist physicians in aligning treatment decisions with patient preferences.CLINICAL RELEVANCE: A ranking tool is a simple, structured process physicians can use to elicit preferences during shared decision making and highlight trade-offs between treatment options to inform treatment choices.

  View details for PubMedID 30797655

• Cost in Hand Surgery: The Patient Perspective. The Journal of hand surgery Alokozai, A., Crijns, T. J., Janssen, S. J., Van Der Gronde, B., Ring, D., Sox-Harris, A., Kamal, R. N. 2019

  Abstract

  PURPOSE: Rising costs at the patient level have been recognized and shown to directly influence patient decisions. By understanding patient interests in discussing cost, hand surgeons may better prepare themselves and their practices to communicate costs with patients.METHODS: We surveyed 128 patients at an upper extremity surgery clinic at their 2-week postoperative visit. Survey domains included basic patient demographics and an assessment of patient financial distress, along with questions that rated patient interest with patient-physician financial conversations. These factors included patients' desire for a conversation regarding cost, whether or not patients have discussed cost with their surgeon, barriers to these discussions, and overall views concerning cost containment in hand care.RESULTS: Seven percent of patients discussed the costs of their surgical care with their physician. Eleven percent of patients reported that a doctor should not discuss the costs of their surgical care. Forty-eight percent of patients reported that a doctor should initiate a conversation regarding costs of care when a new treatment is being considered. Fifty-nine percent of patients agreed that physicians should consider the amount of money a patient will have to pay when choosing a new treatment.CONCLUSIONS: Patients can experience financial hardship as a result of their surgery and some patients are interested in discussing costs with their doctor. Patients indicated that doctors should be concerned with lowering the costs of surgery and should initiate a conversation regarding costs of care when a new treatment is being considered.CLINICAL RELEVANCE: Patients are interested in a conversation regarding their cost of hand surgery care. Making cost data more transparent and available to physicians and patients may facilitatecommunication regarding cost of care.

  View details for PubMedID 30797657

• Team Approach: Management of Scapholunate Instability. JBJS reviews Kamal, R. N., Moore, W., Kakar, S. 2019

  View details for PubMedID 30724763

• TEAM APPROACH: MANAGEMENT OF SCAPHOLUNATE INSTABILITY JBJS REVIEWS Kamal, R. N., Moore, W., Kakar, S. 2019; 7 (2)

  View details for DOI 10.2106/JBJS.RVW.18.00021

  View details for Web of Science ID 000466133300002

• Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review JOURNAL OF ORTHOPAEDIC TRAUMA DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019; 33 (2): 104–10

  View details for DOI 10.1097/BOT.0000000000001372

  View details for Web of Science ID 000467804300017

• Orthopaedic Trauma Quality Measures for Value Based Healthcare Delivery: A Systematic Review. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

  View details for PubMedID 30624346

• Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859

  Abstract

  The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

  View details for DOI 10.1186/s12913-019-4640-x

  View details for PubMedID 31752856

• Patient Preferences for Shared Decision Making: Not All Decisions Should Be Shared. The Journal of the American Academy of Orthopaedic Surgeons E Lindsay, S. n., Alokozai, A. n., Eppler, S. L., Fox, P. n., Curtin, C. n., Gardner, M. n., Avedian, R. n., Palanca, A. n., Abrams, G. D., Cheng, I. n., Kamal, R. N. 2019

  Abstract

  To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition.One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]).Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles.Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

  View details for DOI 10.5435/JAAOS-D-19-00146

  View details for PubMedID 31567900

• Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty? Clinical orthopaedics and related research Li, K. n., Jiang, S. Y., Burn, M. B., Kamal, R. N. 2019

  Abstract

  Although current guidelines do not recommend the routine use of surgical antibiotic prophylaxis to reduce the risk of surgical site infection following clean, soft tissue hand surgery, antibiotics are nevertheless often used in patients with an existing joint prosthesis to prevent periprosthetic joint infection (PJI), despite little data to support this practice.(1) Is clean, soft tissue hand surgery after THA or TKA associated with PJI risk? (2) Does surgical antibiotic prophylaxis before hand surgery decrease PJI risk in patients with recent THA or TKA?We assessed all patients who underwent THA or TKA between January 2007 and December 2015 by retrospective analysis of the IBM® MarketScan® Databases, which provide a longitudinal view of all healthcare services used by a nationwide sample of millions of patients under commercial and supplemental Medicare insurance coverage-particularly advantageous given the relatively low frequency of hand surgery after THA/TKA and of subsequent PJI. The initial search yielded 940,861 patients, from which 509,896 were excluded for not meeting continuous enrollment criteria, having a diagnosis of PJI before the observation period, or having another arthroplasty procedure before or during the observation period; the final study cohort consisted of 430,965 patients of which 147,398 underwent THA and 283,567 underwent TKA. In the treated cohort, 8489 patients underwent carpal tunnel release, trigger finger release, ganglion or retinacular cyst excision, de Quervain's release, or soft-tissue mass excision within 2 years of THA or TKA. The control cohort was comprised of 422,476 patients who underwent THA or TKA but did not have subsequent hand surgery. The primary outcome was diagnosis or surgical management of a PJI within 90 days of the index hand surgery for the treated cohort, or within a randomly assigned 90-day observation period for each patient in the control group. Propensity score matching was used to match treated and control cohorts by patient and treatment characteristics and previously-reported risk factors for PJI. Logistic regression before and after propensity score matching was used to assess the association of hand surgery with PJI risk and the association of surgical antibiotic prophylaxis before hand surgery with PJI risk in the treated cohort. Other possible PJI risk factors were also explored in multivariable logistic regression. Statistical significance was assessed at α = 0.01.Hand surgery was not associated with PJI risk after propensity score matching of treated and control cohorts (OR, 1.39; 99% CI, 0.60-3.22; p = 0.310). Among patients who underwent hand surgery after arthroplasty, surgical antibiotic prophylaxis before hand surgery was not associated with decreased PJI risk (OR 0.42; 99% CI, 0.03-6.08; p = 0.400).Clean, soft-tissue hand surgery was not found to be associated with PJI risk in patients who had undergone primary THA or TKA within 2 years before their hand procedure. While the effect of PJIs can be devastating, we do not find increased risk of infection with hand surgery nor data supporting routine use of surgical antibiotic prophylaxis in this setting.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000000801

  View details for PubMedID 31389880

• National Trends in the Diagnosis of CRPS after Open and Endoscopic Carpal Tunnel Release. Journal of wrist surgery Mertz, K. n., Trunzter, J. n., Wu, E. n., Barnes, J. n., Eppler, S. L., Kamal, R. N. 2019; 8 (3): 209–14

  Abstract

  Background  Complex regional pain syndrome (CRPS) occurs in 2 to 8% of patients that receive open or endoscopic carpal tunnel release (CTR). Because CRPS is difficult to treat after onset, identifying risk factors can inform prevention. We determined the incidence of CRPS following open and endoscopic CTR using a national claims database. We also examined whether psychosocial conditions were associated with CRPS after CTR. Methods  We accessed insurance claims using diagnostic and procedural codes. We calculated the incidence of CRPS following open carpal tunnel release and endoscopic carpal tunnel release within 1 year. The response variable was the presence of CRPS after CTR. Explanatory variables included procedure type, age, gender, and preoperative diagnosis of anxiety or depression. Results  The number of open CTRs (85% of total) outweighs the number of endoscopic procedures. In younger patients, the percentage of endoscopic CTRs is increasing. Rates of CRPS are nearly identical between surgery types for both privately insured (0.3%) and Medicare patients (0.1%). Middle aged (range: 40-64 years) and female patients had significantly higher rates of CRPS than did the general population. Preoperative psychosocial conditions did not correlate with the presence of CRPS in surgical patients. Clinical Relevance  The decision between endoscopic and open CTR should not be made out of concern for development of CRPS postsurgery, as rates are low and similar for both procedures. Rates of CRPS found in this study are much lower than rates found in previous studies, indicating inconsistency in diagnosis and reporting or generalizability of prior work. Preoperative psychosocial disorders and CRPS are unrelated.

  View details for DOI 10.1055/s-0039-1678674

  View details for PubMedID 31192042

  View details for PubMedCentralID PMC6546494

• Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument? Clinical orthopaedics and related research Shapiro, L. M., Harris, A. H., Eppler, S. L., Kamal, R. N. 2019

  Abstract

  Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.(1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points?During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14.In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019).Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000000731

  View details for PubMedID 31107324

• Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries. The Journal of hand surgery Zhuang, T., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.METHODS: We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.RESULTS: Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR]= 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR= 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR= 0.43) and privately insured (adjusted OR= 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.CONCLUSIONS: Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.CLINICAL RELEVANCE: Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

  View details for PubMedID 30579689

• Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System. The Journal of hand surgery Sears, E. D., Meerwijk, E. L., Schmidt, E. M., Kerr, E. A., Chung, K. C., Kamal, R. N., Harris, A. H. 2018

  Abstract

  PURPOSE: To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA).METHODS: A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels.RESULTS: Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level.CONCLUSIONS: There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use.CLINICAL RELEVANCE: Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.

  View details for PubMedID 30579690

• Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study. The Journal of hand surgery Kamal, R. N., Behal, R. 2018

  Abstract

  PURPOSE: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center.METHODS: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost).RESULTS: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs.CONCLUSIONS: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center.CLINICAL RELEVANCE: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.

  View details for PubMedID 30502930

• The Role of Patient Research in Patient Trust in Their Physician. The Journal of hand surgery Lu, L. Y., Sheikholeslami, N., Alokozai, A., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: Trust is foundational to the patient-physician relationship. However, there is limited information on the patient characteristics and behaviors that are related to patient trust. We investigated whether the time patients spend researching their physician and/or symptoms before a clinic visit was correlated with patient trust in their hand surgeon.METHODS: We conducted a prospective study of new patients (n= 134) who presented to a hand surgery clinic. We tested the null hypothesis that time spent researching the physician or symptom does not correlate with physician trust. Secondarily, we tested the association of a maximizing personality (a decision-making personality type defined as one who exhaustively searches for the "best option" as opposed to a "satisficer" who settles for the "good enough" decision) with time spent researching the hand surgeon and patient symptoms, general self-efficacy (one's ability tomanage adversity), and patient trust. Patients completed a questionnaire assessing demographics, patient researching behavior, general self-efficacy (GSE-6), maximizing personality(Maximization Short Form), and physician trust (Trust in Physician Form).RESULTS: The average age of our cohort was 50 ± 17 years, and men and women were equally represented. Patients spent more time researching their symptoms (median, 60 min; range, 5-1,201 min) than they did researching their physician (median, 20 min; range, 1-1,201 min). There was no correlation between time spent by patients seeking information on their hand surgeon and/or symptoms with patient trust in their physician. However, female patients were significantly more trusting of their physician than male patients.CONCLUSIONS: Most patients research their symptoms before clinic, whereas about half research their physicians before meeting them. Time spent seeking information before clinic was not correlated with patient trust in their physician. However, in our study, female patients were more likely to trust their hand surgeon than male patients. Thus, modifying physician behavior rather than patient characteristics may be a stronger driver of patient trust.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

  View details for PubMedID 30366736

• Quality Measures in Foot and Ankle Care. The Journal of the American Academy of Orthopaedic Surgeons Xiong, G., Bennett, C. G., Chou, L., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.METHODS: National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.RESULTS: Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).CONCLUSIONS: Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.5435/JAAOS-D-17-00733

  View details for PubMedID 30325881

• Quality Measures in Total Hip and Total Knee Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons Amanatullah, D. F., McQuillan, T., Kamal, R. N. 2018

  Abstract

  INTRODUCTION: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures.METHODS: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search.RESULTS: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%).CONCLUSION: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement.LEVEL OF EVIDENCE: Level I, systematic review of level I evidence.

  View details for PubMedID 30303844

• Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration Sox-Harris, A., Meerwijk, E. L., Kamal, R. N., Sears, E., Finlay, A. K., Hawn, M. T., Eisenberg, D., Mudumbai, S. ELSEVIER SCIENCE INC. 2018: E32

  View details for DOI 10.1016/j.jamcollsurg.2018.08.084

  View details for Web of Science ID 000447772500070

• Defining Quality in Hand Surgery From the Patient'sPerspective: A Qualitative Analysis. The Journal of hand surgery Eppler, S. L., Kakar, S., Sheikholeslami, N., Sun, B., Pennell, H., Kamal, R. N. 2018

  Abstract

  PURPOSE: Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.METHODS: A steering committee (n= 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.RESULTS: We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.CONCLUSIONS: Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.CLINICAL RELEVANCE: Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

  View details for PubMedID 30031599

• Financial Distress and Discussing the Cost of Total Joint Arthroplasty. The Journal of arthroplasty Amanatullah, D. F., Murasko, M. J., Chona, D. V., Crijns, T. J., Ring, D., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.METHODS: One hundred forty-one patients undergoing elective total hip and knee arthroplasty at a suburban academic medical center were enrolled and completed questionnaires about cost prior to surgery. Questions regarding if and when doctors should discuss the cost of healthcare with patients, evaluating if patients were affected by the cost of healthcare and to what extent, and financial security scores to assess current financial situation were included. The primary outcome was the answer to the question of whether a doctor should discuss cost with patients.RESULTS: Financial stress was found to be associated with patient experience of hardship due to cost of care [P= .004], likelihood to turn down a test or treatment due to copayment [P= .029], to decline a test or treatment due to other costs [P= .003], to experience difficulty affording basic necessities [P= .008], and to have used up all or most of their savings to pay for surgery [P= .011]. In total, 84% of patients reported that they wanted to discuss surgical costs with their doctors, but 90% did not want to do so at every visit.CONCLUSION: Total joint arthroplasty creates considerable out-of-pocket costs that may affect patient decisions. These findings help elucidate important patient concerns that orthopedic surgeons should account for when discussing elective arthroplasty with patients.

  View details for PubMedID 30057266

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for PubMedID 29965894

• Complication rates by surgeon type after open treatment of distal radius fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Truntzer, J., Mertz, K., Eppler, S., Li, K., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons.METHODS: We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported.RESULTS: Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%).CONCLUSIONS: The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 29922979

• Patients Should Define Value in Health Care: A Conceptual Framework. The Journal of hand surgery Kamal, R. N., Lindsay, S. E., Eppler, S. L. 2018

  Abstract

  The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients' preferences when defining value.

  View details for PubMedID 29754755

• The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Gil, J. A., Goodman, A. D., Kleiner, J., Kamal, R. N., Baker, L. C., Akelman, E. 2018; 476 (5): 925–31

  Abstract

  The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics.(1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state?We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design.There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014.After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care.Level III, therapeutic study.

  View details for PubMedID 29672327

• The Sigmoid Notch View for Distal Radius Fractures. The Journal of hand surgery Kamal, R. N., Leversedge, F., Ruch, D. S., Mithani, S. K., Cotterell, I. H., Richard, M. J. 2018

  Abstract

  PURPOSE: This study defines the sigmoid notch view of the distal radius. Specifically, we tested the null hypothesis that there is no relationship between the subchondral stripe of bone seen on a sigmoid notch view of the distal radius and the articular surface of the sigmoid notch.METHODS: We used 44 wrist specimens for anatomic and fluoroscopic analysis. We measured the articular depth of the sigmoid notch from its deepest point and classified the shape of the sigmoid notch. We then placed a radiopaque marker at the nadir of the articular surface and quantified the fluoroscopic depth of the sigmoid notch. A sigmoid notch view, which was a tangential fluoroscopic view of the volar and dorsal lips of the sigmoid notch, was obtained. The relationship of the articular surface to the stripe of subchondral bone seen on this view, called the sigmoid stripe, was determined.RESULTS: Anatomic analysis revealed sigmoid notch types with proportions similar to those in previous descriptions. The marker for the articular surface was superimposed or just ulnar to the sigmoid stripe in all specimens. In flat face and ski slope notches, this was coincident with the volar and dorsal lips of the sigmoid notch. In C- and S-type notches, there was a measurable distance from the articular surface marker to the edges of the bone of the volar and dorsal lips of the sigmoid.CONCLUSIONS: The articular surface marker at the nadir of the sigmoid notch is always coincident or ulnar to the sigmoid stripe in the sigmoid notch view.CLINICAL RELEVANCE: Surgeons can use the sigmoid notch view as a reliable method to (1) evaluate the integrity of the articular surface, (2) ensure hardware is not placed in the distal radioulnar joint, and (3) guide placement of volar locking plates in the coronal plane.

  View details for PubMedID 29680335

• Does Wrist Laxity Influence Three-Dimensional Carpal Bone Motion? JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Best, G. M., Zec, M. L., Pichora, D. R., Kamal, R. N., Rainbow, M. J. 2018; 140 (4)

  View details for DOI 10.1115/1.4038897

  View details for Web of Science ID 000426560800007

• Does Wrist Laxity Influence Three-Dimensional Carpal Bone Motion? Journal of biomechanical engineering Best, G. M., Zec, M. L., Pichora, D. R., Kamal, R. N., Rainbow, M. J. 2018; 140 (4)

  Abstract

  Previous two-dimensional (2D) studies have shown that there is a spectrum of carpal mechanics that varies between row-type motion and column-type motion as a function of wrist laxity. More recent three-dimensional (3D) studies have suggested instead that carpal bone motion is consistent across individuals. The purpose of this study was to use 3D methods to determine whether carpal kinematics differ between stiffer wrists and wrists with higher laxity. Wrist laxity was quantified using a goniometer in ten subjects by measuring passive wrist flexion-extension (FE) range of motion (ROM). In vivo kinematics of subjects' scaphoid and lunate with respect to the radius were computed from computed tomography (CT) volume images in wrist radial and ulnar deviation positions. Scaphoid and lunate motion was defined as "column-type" if the bones flexed and extended during wrist radial-ulnar deviation (RUD), and "row-type" if the bones radial-ulnar deviated during wrist RUD. We found that through wrist RUD, the scaphoid primarily flexed and extended, but the scaphoids of subjects with decreased laxity had a larger component of RUD (R2 = 0.48, P < 0.05). We also determined that the posture of the scaphoid in the neutral wrist position predicts wrist radial deviation (RD) ROM (R2 = 0.46, P < 0.05). These results suggest that ligament laxity plays a role in affecting carpal bone motion of the proximal row throughout radial and ulnar deviation motions; however, other factors such as bone position may also affect motion. By developing a better understanding of normal carpal kinematics and how they are affected, this will help physicians provide patient-specific approaches to different wrist pathologies.

  View details for DOI 10.1115/1.4038897

  View details for PubMedID 29305609

• What Is the State of Quality Measurement in Spine Surgery? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Bennett, C., Xiong, G., Hu, S., Wood, K., Kamal, R. N. 2018; 476 (4): 725–31

  Abstract

  Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

  View details for PubMedID 29480884

• Tensile and Torsional Structural Properties of the Native Scapholunate Ligament. The Journal of hand surgery Pang, E. Q., Douglass, N., Behn, A., Winterton, M., Rainbow, M. J., Kamal, R. N. 2018

  Abstract

  PURPOSE: The ideal material for reconstruction of the scapholunate interosseous ligament (SLIL) should replicate the mechanical properties of the native SLIL to recreate normal kinematics and prevent posttraumatic arthritis. The purpose of our study was to evaluate the cyclic torsional and tensile properties of the native SLIL and load to failure tensile properties of the dorsal SLIL.METHODS: The SLIL bone complex was resected from 10 fresh-frozen cadavers. The scaphoid and lunate were secured in polymethylmethacrylate and mounted on a test machine that incorporated an x-y stage and universal joint, which permitted translations perpendicular to the rotation/pull axis as well as nonaxial angulations. After a 1 N preload, specimens underwent cyclic torsional testing (±0.45 N m flexion/extension at 0.5 Hz) and tensile testing (1-50 N at 1 Hz) for 500 cycles. Lastly, the dorsal 10 mm of the SLIL was isolated and displaced at 10 mm/min until failure.RESULTS: During intact SLIL cyclic torsional testing, the neutral zone was 29.7° ± 6.6° and the range of rotation 46.6° ± 7.1°. Stiffness in flexion and extension were 0.11 ± 0.02 and 0.12 ± 0.02 N m/deg, respectively. During cyclic tensile testing, the engagement length was 0.2 ± 0.1 mm, the mean stiffness was 276 ± 67 N/mm, and the range of displacement was 0.4 ± 0.1 mm. The dorsal SLIL displayed a 0.3 ± 0.2 mm engagement length, 240 ± 65 N/mm stiffness, peak load of 270 ± 91 N, and displacement at peak load of 1.8 ± 0.3 mm.CONCLUSIONS: We report the torsional properties of the SLIL. Our novel test setup allows for free rotation and translation, which reduces out-of-plane force application. This may explain our observation of greater dorsal SLIL load to failure than previous reports.CLINICAL RELEVANCE: By matching the natural ligament with respect to its tensile and torsional properties, we believe that reconstructions will better restore the natural kinematics of the wrist and lead to improved outcomes. Future clinical studies should aim to investigate this further.

  View details for PubMedID 29459171

• Effectiveness of Preoperative Antibiotics in Preventing Surgical Site Infection After Common Soft Tissue Procedures of the Hand. Clinical orthopaedics and related research Li, K. n., Sambare, T. D., Jiang, S. Y., Shearer, E. J., Douglass, N. P., Kamal, R. N. 2018

  Abstract

  Antibiotic prophylaxis is a common but controversial practice for clean soft tissue procedures of the hand, such as carpal tunnel release or trigger finger release. Previous studies report no substantial reduction in the risk of surgical site infection (SSI) after antibiotic prophylaxis, yet are limited in power by low sample sizes and low overall rates of postoperative infection.Is there evidence that antibiotic prophylaxis decreases the risk of SSI after soft tissue hand surgery when using propensity score matching to control for potential confounding variables such as demographics, procedure type, medication use, existing comorbidities, and postoperative events?This retrospective analysis used the Truven Health MarketScan databases, large, multistate commercial insurance claims databases corresponding to inpatient and outpatient services and outpatient drug claims made between January 2007 and December 2014. The database includes records for patients enrolled in health insurance plans from self-insured employers and other private payers. Current Procedural Terminology codes were used to identify patients who underwent carpal tunnel release, trigger finger release, ganglion and retinacular cyst excision, de Quervain's release, or soft tissue mass excision, and to assign patients to one of two cohorts based on whether they had received preoperative antibiotic prophylaxis. We identified 943,741 patients, of whom 426,755 (45%) were excluded after meeting one or more exclusion criteria: 357,500 (38%) did not have 12 months of consecutive insurance enrollment before surgery or 1 month of enrollment after surgery; 60,693 (6%) had concomitant bony, implant, or incision and drainage or débridement procedures; and 94,141 (10%) did not have complete data. In all, our initial cohort consisted of 516,986 patients, among whom 58,201 (11%) received antibiotic prophylaxis. Propensity scores were calculated and used to create cohorts matched on potential risk factors for SSI, including age, procedure type, recent use of steroids and immunosuppressive agents, diabetes, HIV/AIDs, tobacco use, obesity, rheumatoid arthritis, alcohol abuse, malnutrition, history of prior SSI, and local procedure volume. Multivariable logistic regression before and after propensity score matching was used to test whether antibiotic prophylaxis was associated with a decrease in the risk of SSI within 30 days after surgery.After controlling for patient demographics, hand procedure type, medication use, existing comorbidities (eg, diabetes, HIV/AIDs, tobacco use, obesity), and postoperative events through propensity score matching, we found that the risk of postoperative SSI was no different between patients who had received antibiotic prophylaxis and those who had not (odds ratio, 1.03; 95% CI, 0.93-1.13; p = 0.585).Antibiotic prophylaxis for common soft tissue procedures of the hand is not associated with reduction in postoperative infection risk. While our analysis cannot account for factors that are not captured in the billing process, this study nevertheless provides strong evidence against unnecessary use of antibiotics before these procedures, especially given the difficulty of conducting a randomized prospective study with a sample size large enough to detect the effect of prophylaxis on the low baseline risk of infection.Level III, therapeutic study.

  View details for PubMedID 29432267

• High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years. Clinical orthopaedics and related research Gil, J. A., Kamal, R. N., Cone, E., Weiss, A. C. 2017; 475 (12): 3082-3087

  Abstract

  Total wrist arthroplasty (TWA) has been described as traditionally being performed with fixation in the radius and carpus with cement. The TWA implant used in our series has been associated with promising results in studies with up to 6 years followup; however, studies evaluating survivorship, pain, and function with this implant are limited. QUESTION/PURPOSE: (1) To report ROM and pain scores after wrist reconstruction with cementless fourth-generation TWA at a mean followup of 9 years (range, 4.8-14.7 years). (2) To report complications of a cementless fourth-generation TWA and the cumulative probability of not undergoing a revision at a mean followup of 9 years.This is a retrospective case series of 69 patients who were treated for pancarpal wrist arthritis between 2002 and 2014. Of those, 31 had inflammatory arthritis (rheumatoid arthritis [n = 29], juvenile rheumatoid arthritis [n = 1], and psoriatic arthritis [n = 1]); all of these patients received TWA with the cementless implant studied in this investigation. Another 38 patients had osteoarthritis or posttraumatic arthritis; in this subgroup, 28 patients were 65 years or younger, and all underwent wrist fusion (none were offered TWA). Ten patients with osteoarthritis were older than 65 years and all were offered TWA; of those, eight underwent TWA, and two declined the procedure and instead preferred and underwent total wrist arthrodesis. The mean age of the 39 patients who had TWA was 56 ± 8.9 years (range, 31-78 years) at the time of surgery; 36 were women and three were men. The patients who underwent TWA were seen at a minimum of 4 years (mean, 9 years; range, 4-15 years), and all had been examined in 2016 as part of this study except for one patient who died 9 years after surgery. The dominant wrist was involved in 60% (25) of the patients. All patients were immobilized for 4 weeks postoperatively and then underwent hand therapy for 4 to 6 weeks. Pain and ROM were gathered before surgery as part of clinical care, and were measured again at latest followup; at latest followup, radiographs were analyzed (by the senior author) for evidence of loosening, defined as any implant migration compared with any previous radiograph with evidence of periimplant osteolysis and bone resorption. Subjective pain score was assessed by a verbal pain scale (0-10) and ROM was measured with a goniometer. Complications were determined by chart review and final examination. Kaplan Meier survival analysis was performed to estimate the cumulative probability of not undergoing a revision.The mean preoperative active ROM was 34o ± 18° flexion and 36° ± 18° extension. Postoperatively, the mean active ROM was 37° ± 14° flexion and 29° ± 13° extension. The mean difference between the preoperative pain score (8.6 ± 1.2) and postoperative pain score (0.4 ± 0.8) was 8.1 ± 1.9 (p < 0.001). Implant loosening occurred in three (7.7%) patients. No other complications occurred in this series. Kaplan-Meier survivorship analysis estimated the cumulative probability of remaining free from revision as 78% (95% CI, 62%-91%) at 15 years.Cementless fourth-generation TWA improves pain while generally preserving the preoperative arc of motion. The cumulative probability of remaining free from revision at 14.7 years after the index procedure is 77.7% (95% CI, 62.0%-91.4%). Future studies should compare alternative approaches for patients with endstage wrist arthritis; such evaluations-which might compare TWA implants, or TWAs with arthrodesis-will almost certainly need to be multicenter, as the problem is relatively uncommon.Level IV, therapeutic study.

  View details for DOI 10.1007/s11999-017-5445-z

  View details for PubMedID 28721601

  View details for PubMedCentralID PMC5670059

• Treatment Trends in Older Adults With Midshaft Clavicle Fractures JOURNAL OF HAND SURGERY-AMERICAN VOLUME Pang, E., Zhang, S., Harris, A. S., Kamal, R. N. 2017; 42 (11): 875–82

  Abstract

  We present a retrospective administrative claims database review examining the effect of recent literature supporting surgical clavicle fixation in a primarily young male population, on the treatment of midshaft clavicle fractures in patients older than 65 years. We tested the null hypothesis that there is no change in trends in surgical fixation of midshaft clavicle fractures in patients older than 65 years. Secondary analysis examined overall trends and trends based on sex.Data from 2007 to 2012 were extracted using the Medicare Standard Analytic File and Humana administrative claim databases contained within the PearlDiver Patient Records Database. Patients with clavicle shaft fractures and their treatments were identified by International Classification of Disease, Ninth Revision, and Current Procedural Terminology codes. The primary response variable was the proportion of surgical to nonsurgical cases per year, and explanatory variables included age and sex. Data were analyzed using a trend in proportions test with significance set at P less than .05.A total of 32,929 patients with clavicle shaft fractures were identified. During the study period, the proportion of clavicle shaft fractures treated surgically in patients older than 65 years (2.4%-4.6%) and younger than 65 years (11.2%-16.4%) showed a significant increasing trend. When analyzed by both sex and age, there was also an increasing trend in the proportion of surgically treated males in the older than 65 years (3.3%-6.2%) and the younger than 65 years groups (10.9%-19.5%). Lastly, there was an increase in the proportion of surgically treated females older than 65 years (1.7%-3.4%) and younger than 65 years (12.1%-14.3%).Our analysis demonstrates an overall increase in the proportion of surgically treated clavicle shaft fractures, including in the male and female population older than 65 years. In the setting of an aging population, future research evaluating possible benefits of surgical intervention in this population is needed prior to adopting this practice pattern.II.

  View details for PubMedID 28844775

• Quality Measures in Orthopaedic Sports Medicine: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Abrams, G. D., Greenberg, D. R., Dragoo, J. L., Safran, M. R., Kamal, R. N. 2017; 33 (10): 1896–1910

  Abstract

  To report the current quality measures that are applicable to orthopaedic sports medicine physicians.Six databases were searched with a customized search term to identify quality measures relevant to orthopaedic sports medicine surgeons: MEDLINE/PubMed, EMBASE, the National Quality Forum (NQF) Quality Positioning System (QPS), the Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse (NQMC), the Physician Quality Reporting System (PQRS) database, and the American Academy of Orthopaedic Surgeons (AAOS) website. Results were screened by 2 Board-certified orthopaedic surgeons with fellowship training in sports medicine and dichotomized based on sports medicine-specific or general orthopaedic (nonarthroplasty) categories. Hip and knee arthroplasty measures were excluded. Included quality measures were further categorized based on Donabedian's domains and the Center for Medicare and Medicaid (CMS) National Quality Strategy priorities.A total of 1,292 quality measures were screened and 66 unique quality measures were included. A total of 47 were sports medicine-specific and 19 related to the general practice of orthopaedics for a fellowship-trained sports medicine specialist. Nineteen (29%) quality measures were collected within PQRS, with 5 of them relating to sports medicine and 14 relating to general orthopaedics. AAOS Clinical Practice Guidelines (CPGs) comprised 40 (60%) of the included measures and were all within sports medicine. Five (8%) additional measures were collected within AHRQ and 2 (3%) within NQF. Most quality measures consist of process rather than outcome or structural measures. No measures addressing concussions were identified.There are many existing quality measures relating to the practice of orthopaedic sports medicine. Most quality measures are process measures described within PQRS or AAOS CPGs.Knowledge of quality measures are important as they may be used to improve care, are increasingly being used to determine physician reimbursement, and can inform future quality measure development efforts.

  View details for PubMedID 28655476

• Volar Capsular Release After Distal RadiusFractures. The Journal of hand surgery Kamal, R. N., Ruch, D. S. 2017

  Abstract

  PURPOSE: Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).METHODS: We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.RESULTS: Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.CONCLUSIONS: Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 28917548

• Cost Minimization Analysis of Ganglion Cyst Excision. The Journal of hand surgery Pang, E. Q., Zhang, S., Harris, A. H., Kamal, R. N. 2017; 42 (9)

  Abstract

  PURPOSE: Cost minimization analysis can be employed to determine the least costly option when multiple treatments lead to equivalent outcomes. We present a cost minimization analysis from the payers' perspective, of the direct per patient cost of arthroscopic versus open ganglion cyst excision. We tested the null hypothesis that there is no difference in cost between the 2 procedures from the payer perspective.METHODS: We utilized data from a private payer administrative claims database comprising 16 million individuals from 2007 to 2015. Using Current Procedural Terminology codes to identify open and arthroscopic ganglion excisions, we extracted demographic data and fees paid to providers and facilities for the procedure.RESULTS: We identified 5,119 patients undergoing open ganglion cyst excision and 20 patients undergoing arthroscopic ganglion excision. The average cost of an open excision was significantly lower than an arthroscopic excision ($1,821 vs $3,668).CONCLUSIONS: Surgical costs from arthroscopic ganglion excision are significantly more thanopen excision. This data can inform health systems participating in value-based models.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis IV.

  View details for PubMedID 28606435

• PERIOPERATIVE SMOKING CESSATION AND CLINICAL CARE PATHWAY FOR ORTHOPAEDIC SURGERY JBJS REVIEWS Truntzer, J., Comer, G., Kendra, M., Johnson, J., Behal, R., Kamal, R. N. 2017; 5 (8): e11

  View details for PubMedID 28832347

• Evidence-Based Medicine: Surgical Management of Flexor Tendon Lacerations PLASTIC AND RECONSTRUCTIVE SURGERY Kamal, R. N., Yao, J. 2017; 140 (1): 130E–139E

  Abstract

  After reading this article, the participant should be able to: 1. Accurately diagnose a flexor tendon injury. 2. Develop a surgical approach with regard to timing, tendon repair technique, and rehabilitation protocol. 3. List the potential complications following tendon repair.Flexor tendon lacerations are complex injuries that require a thorough history and physical examination for accurate diagnosis and management. Knowledge of operative approaches and potential concomitant injuries allows the surgeon to be prepared for various findings during exploration. Understanding the biomechanical principles behind tendon lacerations and repair techniques aids the surgeon in selecting the optimal repair technique and postoperative rehabilitation.

  View details for PubMedID 28654614

• Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. journal of the American Academy of Orthopaedic Surgeons Truntzer, J. N., Triana, B., Harris, A. H., Baker, L., Chou, L., Kamal, R. N. 2017; 25 (6): 449-457

  Abstract

  Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.III, Economic Decision Analysis.

  View details for DOI 10.5435/JAAOS-D-16-00553

  View details for PubMedID 28459710

• Quality Measures in Breast Reconstruction: A Systematic Review. Annals of plastic surgery Nazerali, R. N., Finnegan, M. A., Divi, V., Lee, G. K., Kamal, R. N. 2017

  Abstract

  The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.

  View details for DOI 10.1097/SAP.0000000000001088

  View details for PubMedID 28570449

• Association of Lunate Morphology With Carpal Instability in Scapholunate Ligament Injury. Hand (New York, N.Y.) Pang, E. Q., Douglass, N., Kamal, R. N. 2017: 1558944717709073-?

  Abstract

  We examined the relationship between lunate morphology (type 1 without a medial facet; type II with a medial facet) and dorsal intercalated segmental instability (DISI) in patients with scapholunate ligament injuries. We tested the primary null hypothesis that there is no relationship between lunate morphology and development of DISI. Secondary analysis compared the agreement of classifying lunate morphology based on the presence of a medial lunate facet, capitate-to-triquetrum (CT) distance, and magnetic resonance imaging (MRI).We performed a retrospective chart review of patients with known scapholunate ligament injuries from 2001 to 2016. Posterior-anterior radiographs and MRI, when available, were evaluated. CT distances were measured as a secondary classification method. DISI and scapholunate instability were determined as radiolunate angle >15° and scapholunate angle >60°, respectively. Differences between groups were determined using chi-square analysis with significance set at P < .05. Agreement between plain radiographs, MRI, and CT distance was calculated using the kappa statistic.Our search found 58 of 417 patients who met inclusion criteria; 41 of 58 had type II and 17 of 58 had type I lunates. There was no significant difference between groups in regard to DISI or scapholunate instability. Subanalysis using MRI alone or correcting any discrepancy between plain film and MRI classification, using MRI as the standard, found no difference between groups in regard to DISI or scapholunate instability.In patients with scapholunate ligament injuries, there are no differences in the development of DISI or scapholunate instability between patients with type I and type II lunates.

  View details for DOI 10.1177/1558944717709073

  View details for PubMedID 28525962

• Impact of Health Literacy on Time Spent Seeking Hand Care. Hand (New York, N.Y.) Alokozai, A., Bernstein, D. N., Sheikholeslami, N., Uhler, L., Ring, D., Kamal, R. N. 2017: 1558944717708027-?

  Abstract

  Patients with limited health literacy may have less knowledge and fewer resources for efficient access and navigation of the health care system. We tested the null hypothesis that there is no correlation between health literacy and total time spent seeking hand surgery care.New patients visiting a hand surgery clinic at a suburban academic medical center were asked to complete a questionnaire to determine demographics, total time spent seeking hand surgery care, and outcomes. A total of 112 patients were included in this study.We found health literacy levels did not correlate with total time seeking hand surgery care or from booking an appointment to being evaluated in clinic.In this suburban academic medical center, patients with low health literacy do not spend more time seeking hand surgery care and do have longer delays between seeking and receiving care. The finding that-at least in this setting-health literacy does not impact patient time seeking hand care suggests that resources to improve health disparities can be focused elsewhere in the care continuum.

  View details for DOI 10.1177/1558944717708027

  View details for PubMedID 28513193

• Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand. journal of hand surgery Schreiber, J. J., Kamal, R. N., Yao, J. 2017

  Abstract

  Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis.Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity.Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects.By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment.Diagnostic II.

  View details for DOI 10.1016/j.jhsa.2017.01.012

  View details for PubMedID 28242242

• Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

  Abstract

  Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

  View details for PubMedID 27926678

• Quality Measures That Address the Upper Limb JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Ring, D., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Got, C., Blazar, P., Yao, J., Kakar, S. 2016; 41 (11): 1041-1048

  Abstract

  Physicians, health care systems, and payers use quality measures to judge performance and monitor the outcomes of interventions. Practicing upper-limb surgeons desire quality measures that are important to patients and feasible to use, and for which it is fair to hold them accountable.Nine academic upper-limb surgeons completed a RAND/University of California-Los Angeles Delphi Appropriateness process to evaluate the importance, feasibility, and accountability of 134 quality measures identified from systematic review. Panelists rated measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 were equivocal or uncertain, and 7 to 9 were valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), panelists were considered to be in agreement. If 3 or more ratings of a measure were within the 1 to 3 range whereas 3 or more ratings were in the 7 to 9 range, panelists were considered to be in disagreement.There was agreement that 58 of the measures are important (43%), 74 are feasible (55%), and surgeons can be held accountable for 39 (29%). All 3 thresholds were met for 33 measures (25%). A total of 36 reached agreement for being unimportant (48%) and 57 were not suited for surgeon accountability (43%).A minority of upper-limb quality measures were rated as important for care, feasible to complete, and suitable for upper-limb surgeon accountability.Before health systems and payers implement quality measures, we recommend ensuring their importance and feasibility to safeguard against measures that may not improve care and might misappropriate attention and resources.

  View details for DOI 10.1016/j.jhsa.2016.07.107

  View details for Web of Science ID 000387632600001

  View details for PubMedID 27577525

• Carpal Kinematics and Kinetics JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Starr, A., Akelman, E. 2016; 41 (10): 1011-1018

  Abstract

  The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

  View details for DOI 10.1016/j.jhsa.2016.07.105

  View details for Web of Science ID 000385340300008

  View details for PubMedID 27569785

• The Impact of the New Carpal Tunnel Clinical Practice Guidelines. The Journal of hand surgery Kamal, R. N. 2016; 41 (9): e329

  View details for DOI 10.1016/j.jhsa.2016.07.055

  View details for PubMedID 27570229

• Quality and Value in an Evolving Health Care Landscape. journal of hand surgery Kamal, R. N. 2016; 41 (7): 794-799

  Abstract

  Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models.

  View details for DOI 10.1016/j.jhsa.2016.05.016

  View details for PubMedID 27374791

• High Disparity Between Orthopedic Resident Interest and Participation in International Health Electives ORTHOPEDICS Zhang, S., Shultz, P., Daniels, A., Akelman, E., Kamal, R. N. 2016; 39 (4): E680-E686

  Abstract

  Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney U test suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics. 2016; 39(4):e680-e686.].

  View details for DOI 10.3928/01477447-20160419-02

  View details for Web of Science ID 000393105500014

  View details for PubMedID 27111074

• Quality Measurement: A Primer for Hand Surgeons JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Kakar, S., Ruch, D., Richard, M. J., Akelman, E., Got, C., Blazar, P., Ladd, A., Yao, J., Ring, D. 2016; 41 (5): 645-651

  Abstract

  As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

  View details for DOI 10.1016/j.jhsa.2015.10.002

  View details for PubMedID 26576831

• Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Daniels, A. H., Depasse, J. M., Kamal, R. N. 2016; 24 (4): 213-219

  Abstract

  Burnout is a syndrome marked by emotional exhaustion, depersonalization, and low job satisfaction. Rates of burnout in orthopaedic surgeons are higher than those in the general population and many other medical subspecialties. Half of all orthopaedic surgeons show symptoms of burnout, with the highest rates reported in residents and orthopaedic department chairpersons. This syndrome is associated with poor outcomes for surgeons, institutions, and patients. Validated instruments exist to objectively diagnose burnout, although family members and colleagues should be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatment options. Orthopaedic residency programs, departments, and practices should focus on identifying the signs of burnout and implementing prevention and treatment programs that have been shown to mitigate symptoms.

  View details for DOI 10.5435/JAAOS-D-15-00148

  View details for Web of Science ID 000372851200001

  View details for PubMedID 26885712

• Quality Measures in Upper Limb Surgery. journal of bone and joint surgery. American volume Kamal, R. N., Ring, D., Akelman, E., Yao, J., Ruch, D. S., Richard, M., Ladd, A., Got, C., Blazar, P., Kakar, S. 2016; 98 (6): 505-510

  Abstract

  Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented.We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services.We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%).Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.

  View details for DOI 10.2106/JBJS.15.00651

  View details for PubMedID 26984919

• Subject-Specific Carpal Ligament Elongation in Extreme Positions, Grip, and the Dart Thrower's Motion JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Rainbow, M. J., Kamal, R. N., Moore, D. C., Akelman, E., Wolfe, S. W., Crisco, J. J. 2015; 137 (11)

  View details for DOI 10.1115/1.4031580

  View details for Web of Science ID 000362842900006

  View details for PubMedID 26367853

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  Abstract

  The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Deltoid Compartment Syndrome After Prolonged Lateral Decubitus Positioning: A Case Report. JBJS case connector Borenstein, T. R., Cohen, E., McDonnell, M., Kamal, R. N., Hayda, R. A. 2015; 5 (2): e45

  Abstract

  A thirty-six-year-old man fell off a ladder and sustained an open fracture of the distal end of the left humerus. He was taken to the operating room for irrigation, debridement, and fixation of the fracture and was placed in the right lateral decubitus position for over seven hours. He subsequently developed right deltoid compartment syndrome, necessitating emergency compartment release. One year later, he had limited function, with a Disabilities of the Arm, Shoulder and Hand score of 81.3 points.Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.

  View details for DOI 10.2106/JBJS.CC.N.00141

  View details for PubMedID 29252699

• Ulnar shortening osteotomy for distal radius malunion. Journal of wrist surgery Kamal, R. N., Leversedge, F. J. 2014; 3 (3): 181-186

  Abstract

  Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

  View details for DOI 10.1055/s-0034-1384747

  View details for PubMedID 25097811

• Salvage of Distal Radius Nonunion With a Dorsal Spanning Distraction Plate JOURNAL OF HAND SURGERY-AMERICAN VOLUME Mithani, S. K., Srinivasan, R. C., Kamal, R., Richard, M. J., Leversedge, F. J., Ruch, D. S. 2014; 39 (5): 981-984

  Abstract

  Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

  View details for DOI 10.1016/j.jhsa.2014.02.006

  View details for Web of Science ID 000335422200025

  View details for PubMedID 24679491

• Post-traumatic Raynaud's phenomenon following volar plate injury. Rhode Island medical journal (2013) Chodakiewitz, Y. G., Daniels, A. H., Kamal, R. N., Weiss, A. C. 2014; 97 (4): 24-26

  Abstract

  Post-traumatic Raynaud's phenomenon following non-penetrating or non-repetitive injury is rare. We report a case of Raynaud's phenomenon occurring in a single digit 3 months following volar plate avulsion injury. Daily episodes of painless pallor of the digit occurred for 1 month upon any exposure to cold, resolving with warm water therapy. Symptoms resolved after the initiation of hand therapy, splinting, and range-of- motion exercises.

  View details for PubMedID 24660212

• Quality of internet health information on thumb carpometacarpal joint arthritis. Rhode Island medical journal (2013) Kamal, R. N., Paci, G. M., Daniels, A. H., Gosselin, M., Rainbow, M. J., Weiss, A. C. 2014; 97 (4): 31-35

  Abstract

  The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis.The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale.Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015).Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed.The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

  View details for PubMedID 24660214

• Extensive Subcutaneous Emphysema Resembling Necrotizing Fasciitis ORTHOPEDICS Kamal, R. N., Paci, G. M., Born, C. T. 2013; 36 (5): 671-675

  Abstract

  Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

  View details for DOI 10.3928/01477447-20130426-34

  View details for Web of Science ID 000319811900037

  View details for PubMedID 23672900

• Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation. Rhode Island medical journal (2013) Mansuripur, P. K., Deren, M. E., Kamal, R. 2013; 96 (5): 37-39

  Abstract

  Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

  View details for PubMedID 23641462

• Total Wrist Arthroplasty JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Weiss, A. C., Kamal, R. N., Shultz, P. 2013; 21 (3): 140-148

  Abstract

  Over the past 40 years, total wrist arthroplasty (TWA) has emerged as a cost-effective treatment option for wrist arthritis. First-generation implant designs have changed tremendously; current devices are designed to enhance wrist stability, provide greater implant longevity, and minimize surgical and postoperative complications. Although arthrodesis remains the standard for surgical management, TWA outcomes demonstrate that the procedure has excellent clinical promise. Additional prospective studies are needed to compare outcomes of wrist arthrodesis with those of TWA with current implants.

  View details for DOI 10.5435/JAAOS-21-03-140

  View details for Web of Science ID 000317444900003

  View details for PubMedID 23457064

• In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension. journal of hand surgery Rainbow, M. J., Kamal, R. N., Leventhal, E., Akelman, E., Moore, D. C., Wolfe, S. W., Crisco, J. J. 2013; 38 (2): 278-288

  Abstract

  Insights into the complexity of active in vivo carpal motion have recently been gained using 3-dimensional imaging; however, kinematics during extremes of motion has not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension.We obtained computed tomography scans of 12 healthy wrists in neutral grip, extreme loaded flexion, and extreme loaded extension. We obtained 3-dimensional bone surfaces and 6-degree-of-freedom kinematics for the radius and carpals. The flexion and extension rotation from neutral grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared with previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, we used joint space metrics at the radiocarpal and midcarpal joints to describe arthrokinematics.In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral.The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared with wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint.These findings highlight the difference in kinematics of the carpus at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.

  View details for DOI 10.1016/j.jhsa.2012.10.035

  View details for PubMedID 23266007

• The effect of the dorsal intercarpal ligament on lunate extension after distal scaphoid excision. journal of hand surgery Kamal, R. N., Chehata, A., Rainbow, M. J., Llusá, M., Garcia-Elias, M. 2012; 37 (11): 2240-2245

  Abstract

  After a distal scaphoid excision, most wrists develop a mild form of carpal instability-nondissociative with dorsal intercalated segment instability. Substantial dysfunctional malalignment is only occasionally seen. We hypothesized that distal scaphoid excision would lead to carpal instability-nondissociative with dorsal intercalated segment instability in cadavers and that the dorsal intercarpal (DIC) ligament plays a role in preventing such complications.We used 10 cadaver upper extremities in this experiment. A customized jig was used to load the wrist with 98 N. Motion of the capitate and lunate was monitored using the Fastrak motion tracking system. Five specimens had a distal scaphoid excision first, followed by excision of the DIC ligament, whereas the other 5 specimens first had excision of the DIC ligament and then had a distal scaphoid excision. Rotation of the lunate and capitate was calculated as a sum of the relative motions between each intervention and was compared with its original location before intervention (control) for statistical analysis.Distal scaphoid excision and subsequent DIC ligament excision both led to significant lunate extension. DIC ligament excision alone resulted in lunate flexion that was not statistically significant. After DIC ligament excision, distal scaphoid excision led to significant lunate extension. Capitate rotation was minimal in both groups, verifying that the overall wrist position did not change with loading.Distal scaphoid excision leads to significant lunate extension through an imbalance in the force couple between the scaphotrapeziotrapezoidal joint and the triquetrum-hamate joint. The DIC ligament may serve as a secondary stabilizer to the lunocapitate joint and prevent further lunate extension with the wrist in neutral position.The development of a clinically symptomatic carpal instability-nondissociative with dorsal intercalated segment instability with lunocapitate subluxation after distal scaphoid excision may be due to an incompetent DIC ligament.

  View details for DOI 10.1016/j.jhsa.2012.07.029

  View details for PubMedID 23044477

• Elongation of the dorsal carpal ligaments: a computational study of in vivo carpal kinematics. journal of hand surgery Rainbow, M. J., Crisco, J. J., Moore, D. C., Kamal, R. N., Laidlaw, D. H., Akelman, E., Wolfe, S. W. 2012; 37 (7): 1393-1399

  Abstract

  The dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments play an important role in scapholunate and lunotriquetral stability. The purpose of this study was to compute changes in ligament elongation as a function of wrist position for the DRC and the scaphoid and trapezoidal insertions of the DIC.We developed a computational model that incorporated a digital dataset of ligament origin and insertions, bone surface models, and in vivo 3-dimensional kinematics (n = 28 wrists), as well as an algorithm for computing ligament fiber path.The differences between the maximum length and minimum length of the DRC, DIC scaphoid component, and DIC trapezoidal component over the entire range of motion were 5.1 ± 1.5 mm, 2.7 ± 1.5 mm, and 5.9 ± 2.5 mm, respectively. The DRC elongated as the wrist moved from ulnar extension to radial flexion, and the DIC elongated as the wrist moved from radial deviation to ulnar deviation.The DRC and DIC lengthened in opposing directions during wrist ulnar and radial deviation. Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. Errors between computed values and model predictions were less than 2.0 mm across all subjects and positions.The relationships between ligament elongation and wrist position should further our understanding of ligament function, provide insight into the potential effects of dorsal wrist incisions on specific wrist ranges of motion, and serve as a basis for modeling of the wrist.

  View details for DOI 10.1016/j.jhsa.2012.04.025

  View details for PubMedID 22633233

• Updates on Disaster Preparedness and Progress in Disaster Relief JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Pollak, A. N., Born, C. T., Kamal, R. N., Adashi, E. Y. 2012; 20: S54-S58

  Abstract

  Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

  View details for DOI 10.5435/JAAOS-20-08-S54

  View details for Web of Science ID 000307199000013

  View details for PubMedID 22865138

• In Vivo Triquetrum-Hamate Kinematics through a Simulated Hammering Wrist Motion J Bone Joint Surg Am Kamal, R., et al 2012
• The Use of Near-Infrared Spectrometry for the Diagnosis of Lower-extremity Compartment Syndrome ORTHOPEDICS Bariteau, J. T., Beutel, B. G., Kamal, R., Hayda, R., Born, C. 2011; 34 (3)

  View details for DOI 10.3928/01477447-20110124-12

  View details for Web of Science ID 000209016700010

• Total Wrist Athroplasty in the Non-Rheumatoid Patient J Hand Surg Am. Kamal, R. 2011
• Arthroscopic Treatment of Radiocarpal Dislocation: A Case Report Journal of Bone and Joint Surgery Kamal, R., et al 2011
• Effects on cytokines and histology by treatment with the ace inhibitor captopril and the antioxidant retinoic acid in the monocrotaline model of experimentally induced lung fibrosis CURRENT PHARMACEUTICAL DESIGN Baybutt, R. C., Herndon, B. L., Umbehr, J., Mein, J., Xue, Y., Reppert, S., Van Dillen, C., Kamal, R., Halder, A., Moteni, A. 2007; 13 (13): 1327-1333

  Abstract

  Monocrotaline (MCT), a pyrrolizidine alkaloid extracted from the shrub Crotalaria spectabilis, induces in the lungs of many mammalian species severe hypertension and fibrosis. Previous work with MCT-induced lung disease in rats has shown that some of the steps to progressive fibrosis can be interrupted or decreased by intervention with retinoic acid (RA) or with the angiotensin converting enzyme inhibitor, captopril. This report emphasizes the pathology and cytokines present in lungs of rats in the MCT model of hypertension and fibrosis in 8 treatment groups, six per group: (1) controls, not treated; (2) captopril; (3) RA; (4) combined captopril and RA. Groups 5-8 replicated groups 1-4 and also received MCT subcutaneously. Tissues were harvested at 28 days for histopathology and measurement of cytokines TGFbeta, TNFalpha, interleukin 6, and IFN_. TGFbeta was depressed at 28 days by MCT, an effect reversed by a combination of captopril and RA. RA influences production of an important Th1 cytokine, IFN_, and demonstrated the greatest limitation of MCT-induced TNFalpha. The MCT-induced lung pathology of vasculitis, interstitial pneumonia and fibrosis was limited by captopril. Smooth muscle actin was overexpressed in MCT treated animals receiving RA, an effect reduced with captopril. Overall, the study confirmed the existence of a protective effect for both captopril and RA from MCT-induced lung damage at 30 days. No synergistic or antagonistic activity was observed when the two drugs were administered together. Each of the drugs exerts different and particular effects on serum and tissue levels of various cytokines, suggesting that each drug is efficient at different points of attack in the control of lung fibrosis.

  View details for Web of Science ID 000247013200005

  View details for PubMedID 17506718

• Retinoic Acid-High Diet controls M1/M2 Activation Phenotypes in Macrophages and Protects from Monocrotaline-Induced Pulmonary Fibrosis Nutrition Research Kamal, R., et al 2004